Basic Information
| Provider Information | |||||||||
| NPI: | 1639218977 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACKEY | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | H. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1309 MCCARTHY BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285622035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526583156 | ||||||||
| FaxNumber: | 6177622965 | ||||||||
| Practice Location | |||||||||
| Address1: | 1309 MCCARTHY BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW BERN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285622035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2526583156 | ||||||||
| FaxNumber: | 6177622965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 02/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 6708 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 018TE | 01 | NC | BLUE CROSS GROUP BILLING NUMBER | OTHER |