Provider Demographics
NPI:1891991964
Name:RACKOVAN, MARY V (COTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:V
Last Name:RACKOVAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1236 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-3513
Mailing Address - Country:US
Mailing Address - Phone:314-255-8189
Mailing Address - Fax:
Practice Address - Street 1:7601 WATSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-5001
Practice Address - Country:US
Practice Address - Phone:314-961-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004970171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor