Provider Demographics
NPI:1093012999
Name:LUTZ, SHAWN CONRAD (DC)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:CONRAD
Last Name:LUTZ
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 1:2955 N HWY 97 STE 100
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-7559
Mailing Address - Country:US
Mailing Address - Phone:458-206-6123
Mailing Address - Fax:541-600-4731
Practice Address - Street 1:2955 N HWY 97 STE 100
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7559
Practice Address - Country:US
Practice Address - Phone:458-206-6123
Practice Address - Fax:541-600-4731
Is Sole Proprietor?:No
Enumeration Date:2011-02-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACHIR.CH.60226450111N00000X
OR4064111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No111N00000XChiropractic ProvidersChiropractor