Provider Demographics
NPI:1588220834
Name:RUTKOWSKI, SHANE DENNIS (LAC)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:DENNIS
Last Name:RUTKOWSKI
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 17TH ST UNIT 2337
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-1508
Mailing Address - Country:US
Mailing Address - Phone:970-616-0806
Mailing Address - Fax:
Practice Address - Street 1:2949 FEDERAL BLVD STE 233
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-3741
Practice Address - Country:US
Practice Address - Phone:970-616-0806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006525171100000X
COACU.0002746171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist