Healthcare Provider Details

I. General information

NPI: 1609285816
Provider Name (Legal Business Name): DANIEL RACKOVAN ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13537 BARRET PKWY DR 105
BALLWIN MO
63021
US

IV. Provider business mailing address

1256 WOODCHASE LN APARTMENT F
CHESTERFIELD MO
63017
US

V. Phone/Fax

Practice location:
  • Phone: 314-821-9126
  • Fax:
Mailing address:
  • Phone: 314-306-1084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2013004251
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: