Provider Demographics
NPI:1578993606
Name:LUTZ PHYSICAL MEDICINE CORP
Entity Type:Organization
Organization Name:LUTZ PHYSICAL MEDICINE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENESSA
Authorized Official - Middle Name:KALENE
Authorized Official - Last Name:LUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-840-3217
Mailing Address - Street 1:11547 FUELBERTH RD
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-8247
Mailing Address - Country:US
Mailing Address - Phone:309-840-3217
Mailing Address - Fax:
Practice Address - Street 1:3105 N PROSPECT RD
Practice Address - Street 2:JENESSA LUTZ
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603
Practice Address - Country:US
Practice Address - Phone:309-840-3217
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-27
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011261111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1174794200OtherNPI