Healthcare Provider Details

I. General information

NPI: 1215579115
Provider Name (Legal Business Name): MARTHA RACKETA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7785 MOTTICE DR SE APT 319
WAYNESBURG OH
44688-9590
US

IV. Provider business mailing address

7785 MOTTICE DR SE APT 319
WAYNESBURG OH
44688-9590
US

V. Phone/Fax

Practice location:
  • Phone: 330-933-9423
  • Fax:
Mailing address:
  • Phone: 330-933-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberRT786311
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: