Healthcare Provider Details

I. General information

NPI: 1023215811
Provider Name (Legal Business Name): MR. LESLIE PATRICK LUTTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 E FRONT ST
BRONSON IA
51007-5025
US

IV. Provider business mailing address

515 E FRONT ST
BRONSON IA
51007-5025
US

V. Phone/Fax

Practice location:
  • Phone: 712-389-7682
  • Fax: 712-276-2100
Mailing address:
  • Phone: 712-389-7682
  • Fax: 712-276-2100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: