Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician |
NPI | 1013464270 |
---|---|
Provider Name | Jeffery Lackey |
First Address | Oneonta, AL 35121-2756 |
Second Address | Oneonta, AL 35121-2756 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/09/2016 |
Last Update Date | 06/09/2016 |