1578993606 NPI number — LUTZ PHYSICAL MEDICINE CORP

Table of content: (NPI 1578993606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578993606 NPI number — LUTZ PHYSICAL MEDICINE CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUTZ PHYSICAL MEDICINE CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578993606
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11547 FUELBERTH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEKIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61554-8247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-840-3217
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3105 N PROSPECT RD
Provider Second Line Business Practice Location Address:
JENESSA LUTZ
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-840-3217
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/27/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LUTZ
Authorized Official First Name:
JENESSA
Authorized Official Middle Name:
KALENE
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
309-840-3217

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  038011261 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1174794200 . This is a "NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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