Provider Demographics
NPI:1053709865
Name:BOGGAN, LACEY
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:BOGGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41007 N RUNNING DEER LN
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:WA
Mailing Address - Zip Code:99006-5128
Mailing Address - Country:US
Mailing Address - Phone:509-276-0026
Mailing Address - Fax:
Practice Address - Street 1:9 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:WA
Practice Address - Zip Code:99006
Practice Address - Country:US
Practice Address - Phone:509-276-0026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-31
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier