Provider Demographics
NPI:1992977946
Name:DR. LACEY D. PUCKETT & ASSOCIATES, INC
Entity type:Organization
Organization Name:DR. LACEY D. PUCKETT & ASSOCIATES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LACEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:865-544-1677
Mailing Address - Street 1:3001 KNOXVILLE CENTER DR
Mailing Address - Street 2:SUITE 2294
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37924-5044
Mailing Address - Country:US
Mailing Address - Phone:865-544-1677
Mailing Address - Fax:865-525-3467
Practice Address - Street 1:3001 KNOXVILLE CENTER DR
Practice Address - Street 2:SUITE 2294
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37924-5044
Practice Address - Country:US
Practice Address - Phone:865-544-1677
Practice Address - Fax:865-525-3467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN39470653Medicare PIN