Healthcare Provider Details

I. General information

NPI: 1629063466
Provider Name (Legal Business Name): REX ALDEN LUTES O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3464 NEW GERMANY TREBEIN RD
BEAVERCREEK OH
45431-1790
US

IV. Provider business mailing address

3464 NEW GERMANY TREBEIN RD
BEAVERCREEK OH
45431-1790
US

V. Phone/Fax

Practice location:
  • Phone: 937-429-4060
  • Fax: 937-429-9675
Mailing address:
  • Phone: 937-429-4060
  • Fax: 937-429-9675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3478/T747
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: