Provider Demographics
NPI:1710958608
Name:KLUTZ, BRUCE A (PT)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:KLUTZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 SOUTHTOWN DR
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-2635
Mailing Address - Country:US
Mailing Address - Phone:715-839-9266
Mailing Address - Fax:
Practice Address - Street 1:4210 SOUTHTOWN DR
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-2635
Practice Address - Country:US
Practice Address - Phone:715-839-9266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1938-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN413T3KLOtherBXBS
WI36138500Medicaid
WI36138500Medicaid