Provider Demographics
NPI:1790846673
Name:LUTZ, JAMES ROBERT (DC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ROBERT
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 1:2150 CHESTNUT STREET
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-2908
Mailing Address - Country:US
Mailing Address - Phone:262-334-5431
Mailing Address - Fax:262-335-6481
Practice Address - Street 1:2150 CHESTNUT STREET
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-2908
Practice Address - Country:US
Practice Address - Phone:262-334-5431
Practice Address - Fax:262-335-6481
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1965012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T62651Medicare UPIN