MEDICARE: MS. BANDY JO RACKLEY RD, LD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1005X	Renal Nutrition Registered Dietitian

General Provider Information

NPI Number	:	1033188743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BANDY JO RACKLEY RD, LD

Provider Business Mailing Address
First Line	:	PO BOX 485
Second Line	:
City	:	MEDICINE PARK
State	:	OK
Zip	:	73557-0485
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5110 W GORE BLVD
Second Line	:
City	:	LAWTON
State	:	OK
Zip	:	73505-5909
Country	:	US
Telephone Number	:	580-713-3123
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2006
Last Update Date	:	07/22/2022

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