Provider Demographics
NPI:1043263866
Name:MUTZENBERGER, LISA A (DC)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:MUTZENBERGER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:TEKAMAH
Mailing Address - State:NE
Mailing Address - Zip Code:68061-1307
Mailing Address - Country:US
Mailing Address - Phone:402-374-1900
Mailing Address - Fax:
Practice Address - Street 1:435 S 13TH ST
Practice Address - Street 2:
Practice Address - City:TEKAMAH
Practice Address - State:NE
Practice Address - Zip Code:68061-1307
Practice Address - Country:US
Practice Address - Phone:402-374-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1106111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47078788500Medicaid
NE266051Medicare PIN
NEU51860Medicare UPIN
NE47078788500Medicaid