Provider Demographics
NPI:1588177885
Name:LACIDONIA, MICHAEL (LAC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:LACIDONIA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 TERRA VERDE DR UNIT 102
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-5593
Mailing Address - Country:US
Mailing Address - Phone:732-581-4531
Mailing Address - Fax:
Practice Address - Street 1:6400 FALLS OF NEUSE RD STE 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615
Practice Address - Country:US
Practice Address - Phone:919-625-0043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-08
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAC-925171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist