Provider Demographics
NPI:1194925602
Name:RUSTICI, DRAKE ROBERT (DC)
Entity type:Individual
Prefix:DR
First Name:DRAKE
Middle Name:ROBERT
Last Name:RUSTICI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603ANEWOODS CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-1900
Mailing Address - Country:US
Mailing Address - Phone:816-886-2035
Mailing Address - Fax:816-503-8941
Practice Address - Street 1:603ANEWOODS CHAPEL RD
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64064-1900
Practice Address - Country:US
Practice Address - Phone:816-886-2035
Practice Address - Fax:816-503-8941
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2015-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007017726111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA4745002OtherMEDICARE PTAN