Healthcare Provider Details

I. General information

NPI: 1831750108
Provider Name (Legal Business Name): KARA C RACKOVAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 07/11/2022
Certification Date: 07/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 THF BLVD
CHESTERFIELD MO
63005-1141
US

IV. Provider business mailing address

211 E BROADWAY
ALTON IL
62002-6220
US

V. Phone/Fax

Practice location:
  • Phone: 636-537-0700
  • Fax:
Mailing address:
  • Phone: 618-462-9818
  • Fax: 314-741-4947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2019021875
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: