Healthcare Provider Details

I. General information

NPI: 1093816258
Provider Name (Legal Business Name): DOCKTER - LUTZ CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 CIVIC HEIGHTS DR SUITE 108
CIRCLE PINES MN
55014-4711
US

IV. Provider business mailing address

620 CIVIC HEIGHTS DR SUITE 108
CIRCLE PINES MN
55014-4711
US

V. Phone/Fax

Practice location:
  • Phone: 763-795-8300
  • Fax: 763-795-8302
Mailing address:
  • Phone: 763-795-8300
  • Fax: 763-795-8302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3400
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3433
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3573
License Number StateMN

VIII. Authorized Official

Name: MARIA L SKOTTERUD
Title or Position: DIRECTOR OF HUMAN RESOURCES
Credential:
Phone: 763-795-8300