Provider Demographics
NPI:1609101245
Name:RACKMAN, ELANA SHARON (RD)
Entity Type:Individual
Prefix:
First Name:ELANA
Middle Name:SHARON
Last Name:RACKMAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1487 REEVES ST
Mailing Address - Street 2:NO. 3
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-2941
Mailing Address - Country:US
Mailing Address - Phone:917-892-1293
Mailing Address - Fax:
Practice Address - Street 1:435 N. ROXURY DRIVE
Practice Address - Street 2:STE 100
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-5003
Practice Address - Country:US
Practice Address - Phone:310-855-8058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA851000133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA851000OtherLICENSE NUMBER