=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093816258
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOCKTER - LUTZ CHIROPRACTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 08/07/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 CIVIC HEIGHTS DR SUITE 108
-----------------------------------------------------
City | CIRCLE PINES
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55014-4711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-795-8300
-----------------------------------------------------
Fax | 763-795-8302
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 620 CIVIC HEIGHTS DR SUITE 108
-----------------------------------------------------
City | CIRCLE PINES
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55014-4711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-795-8300
-----------------------------------------------------
Fax | 763-795-8302
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF HUMAN RESOURCES
-----------------------------------------------------
Name | MARIA L SKOTTERUD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 763-795-8300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3400
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3433
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3573
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------