Healthcare Provider Details

I. General information

NPI: 1003239989
Provider Name (Legal Business Name): ANDREW RACKOVAN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2014
Last Update Date: 03/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2621 RAYMOND DR
SAINT CHARLES MO
63301-4872
US

IV. Provider business mailing address

2621 RAYMOND DR
SAINT CHARLES MO
63301-4872
US

V. Phone/Fax

Practice location:
  • Phone: 636-946-2244
  • Fax: 636-946-6975
Mailing address:
  • Phone: 636-946-2244
  • Fax: 636-946-6975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2014002027
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: