Healthcare Provider Details

I. General information

NPI: 1366010043
Provider Name (Legal Business Name): MACKENZIE TAYCHERT DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 US HIGHWAY 61
CRYSTAL CTY MO
63028-4108
US

IV. Provider business mailing address

1400 US HIGHWAY 61
CRYSTAL CTY MO
63028-4108
US

V. Phone/Fax

Practice location:
  • Phone: 636-933-5337
  • Fax: 636-933-8090
Mailing address:
  • Phone: 636-933-5337
  • Fax: 636-933-8090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2024034555
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: