Healthcare Provider Details

I. General information

NPI: 1699052126
Provider Name (Legal Business Name): MEGAN DORA MAXWELL LUTZ M.S., L.C.G.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2011
Last Update Date: 11/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 14TH ST STE 502
RIVERSIDE CA
92501-4019
US

IV. Provider business mailing address

4000 14TH ST STE 502
RIVERSIDE CA
92501-4019
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-4675
  • Fax: 951-683-1148
Mailing address:
  • Phone: 951-683-4675
  • Fax: 951-683-1148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: