Provider Demographics
NPI:1568706174
Name:LUTOTN, DANIEL J (LMT)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:J
Last Name:LUTOTN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 S 2ND ST.
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355
Mailing Address - Country:US
Mailing Address - Phone:541-740-9392
Mailing Address - Fax:
Practice Address - Street 1:1555 S 2ND ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-3121
Practice Address - Country:US
Practice Address - Phone:541-740-9392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11574171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR11574OtherOREGON MASSAGE LICENSE