Provider Demographics
NPI:1487904561
Name:LACY EYE CARE SERVICES PC
Entity type:Organization
Organization Name:LACY EYE CARE SERVICES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALKISHUANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LACY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-333-3937
Mailing Address - Street 1:4444 W JEFFERSON BLVD
Mailing Address - Street 2:STE 614
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75211-4600
Mailing Address - Country:US
Mailing Address - Phone:214-333-3937
Mailing Address - Fax:214-331-2021
Practice Address - Street 1:4444 W JEFFERSON BLVD STE 614
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-4611
Practice Address - Country:US
Practice Address - Phone:214-333-3937
Practice Address - Fax:214-331-2021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-14
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX07205TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83032QOtherBLUE CROSS BLUE SHIELD OF TEXAS
TX285030701Medicaid
TXTXB134022Medicare PIN