Healthcare Provider Details

I. General information

NPI: 1023048121
Provider Name (Legal Business Name): LARRY JOHN LUTZ JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MAIN ST
EATON RAPIDS MI
48827-1952
US

IV. Provider business mailing address

7176 CROWN POINTE CIR
PORTAGE MI
49024-4038
US

V. Phone/Fax

Practice location:
  • Phone: 517-663-2671
  • Fax:
Mailing address:
  • Phone: 269-321-8736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704189964
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: