Provider Demographics
NPI:1699375071
Name:LACY, GEORGE M
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:M
Last Name:LACY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6031 E MAIN ST # 167
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-3590
Mailing Address - Country:US
Mailing Address - Phone:614-402-6986
Mailing Address - Fax:
Practice Address - Street 1:6412 LANERCOST RD
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-3516
Practice Address - Country:US
Practice Address - Phone:614-402-6986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRQ399977172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver