Basic Information
| Provider Information | |||||||||
| NPI: | 1700056926 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LACEY | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10933 S CENTRAL PARK AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606553304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737795414 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9634 S PULASKI RD | ||||||||
| Address2: | |||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604533391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084234800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2008 | ||||||||
| LastUpdateDate: | 03/04/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.