Provider Demographics
NPI:1316960917
Name:LUTTRELL, ERIC LEE (DC)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:LEE
Last Name:LUTTRELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041B OAKDALE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4512
Mailing Address - Country:US
Mailing Address - Phone:209-521-9036
Mailing Address - Fax:209-521-3531
Practice Address - Street 1:1041B OAKDALE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-4512
Practice Address - Country:US
Practice Address - Phone:209-521-9036
Practice Address - Fax:209-521-3531
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24486111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0244860OtherBLUESHIELD PROVIDER NUMBE
CADC24486OtherGENERAL INSURANCE NUMBER
CADC0244860Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER