Basic Information
| Provider Information | |||||||||
| NPI: | 1124094388 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACKEY | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | KENNETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 N JUSTICE ST # 16 | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287913410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286948350 | ||||||||
| FaxNumber: | 8286947654 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 N JUSTICE ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287913410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286742433 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 31855 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03-0455058 | 01 | HEALTHCARE SAVINGS | OTHER | 7950512 | 05 | NC | MEDICAID | N31855 | 01 | SC MEDICAID | OTHER | 03-0455058 | 01 | CIGNA HEALTHCARE | OTHER | 50512 | 01 | BCBS NC | OTHER | NCI531A | 01 | NC | MEDICARE PTAN | OTHER | 01-70268 | 01 | UNITED HEALTHCARE | OTHER | 43889 | 01 | MEDCOST | OTHER | 03-0455058 | 01 | CRESENT | OTHER | 080191010 | 01 | RR MEDICARE | OTHER | 354567600 | 01 | OWCP | OTHER | P01413618 | 01 | NC | RR MEDICARE | OTHER |