Provider Demographics
NPI:1588308142
Name:RUCKER, KATRELL
Entity type:Individual
Prefix:
First Name:KATRELL
Middle Name:
Last Name:RUCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CEDAR RUN LN APT 7
Mailing Address - Street 2:
Mailing Address - City:LAKE ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-2707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 CEDAR RUN LN APT 7
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-2707
Practice Address - Country:US
Practice Address - Phone:636-466-7745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)