Provider Demographics
NPI:1033648407
Name:AGARD, LACEY NICOLE
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:NICOLE
Last Name:AGARD
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 1:8449 MONIQUE CT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-6151
Mailing Address - Country:US
Mailing Address - Phone:951-500-8070
Mailing Address - Fax:
Practice Address - Street 1:906 SYCAMORE AVE STE 210
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-7851
Practice Address - Country:US
Practice Address - Phone:760-940-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293053225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist