Provider Demographics
NPI:1831464296
Name:RUTZ, ROGER MARC (LAC)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:MARC
Last Name:RUTZ
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 1:381 N YORK ST
Mailing Address - Street 2:SUITES 1 AND 2
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2342
Mailing Address - Country:US
Mailing Address - Phone:630-479-0314
Mailing Address - Fax:
Practice Address - Street 1:381 N YORK ST
Practice Address - Street 2:SUITES 1 AND 2
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2342
Practice Address - Country:US
Practice Address - Phone:630-479-0314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001012171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist