Healthcare Provider Details

I. General information

NPI: 1568024081
Provider Name (Legal Business Name): LEAH E RUTZ ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2019
Last Update Date: 07/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 BROADWAY AVE
SAINT PETER MN
56082-2258
US

IV. Provider business mailing address

19518 POPLAR ST
MOKENA IL
60448-9323
US

V. Phone/Fax

Practice location:
  • Phone: 708-256-1160
  • Fax:
Mailing address:
  • Phone: 708-256-1160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2240-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: