Organization
JOHN LACKEY, INC
Active
Other names
Dr. John Lackey, Inc.
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JOHN LACKEY D.O. (OWNER)
(304) 872-6433
Entity
Organization
Contact information
Practice address
702 PROFESSIONAL PARK DR, SUITE102, SUMMERSVILLE, WV 26651-2018
(304) 872-6433
(304) 872-6562
Mailing address
702 PROFESSIONAL PARK DR, SUITE 102, SUMMERSVILLE, WV 26651-2018
(304) 872-6433
(304) 872-6562
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
736
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00094926001
MEDICAID OPTICAL SUPPLIER NUMBER
WV
01
—
0257640001
MEDICARE DME PTAN (SUPPLIER PTAN)
WV
01
—
1205951605
MEDICARE GROUP PAYER NPI (MEDICAL PRACTICE)
WV
01
—
1609904663
DME SUPPLIER NPI
WV
Enumeration date
03/01/2007
Last updated
11/03/2011
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