Provider Demographics
NPI:1316820293
Name:LACEY, DARRICK TAYLOR
Entity type:Individual
Prefix:
First Name:DARRICK
Middle Name:TAYLOR
Last Name:LACEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 CEMETERY RD UNIT 10
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-7061
Mailing Address - Country:US
Mailing Address - Phone:208-220-8327
Mailing Address - Fax:
Practice Address - Street 1:3400 S 5TH W
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-7309
Practice Address - Country:US
Practice Address - Phone:208-220-8327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-29
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist