Provider Demographics
NPI:1073675971
Name:MORTENSEN, ERIC G (DC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:G
Last Name:MORTENSEN
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 1:4517 MARKET ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-7710
Mailing Address - Country:US
Mailing Address - Phone:805-650-5929
Mailing Address - Fax:805-650-5947
Practice Address - Street 1:4517 MARKET ST
Practice Address - Street 2:SUITE 1
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-7710
Practice Address - Country:US
Practice Address - Phone:805-650-5929
Practice Address - Fax:805-650-5947
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24888111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor