Provider Demographics
NPI:1467617498
Name:MORT'S CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:MORT'S CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:MORT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:574-594-2711
Mailing Address - Street 1:526 S FIRST ST
Mailing Address - Street 2:
Mailing Address - City:PIERCETON
Mailing Address - State:IN
Mailing Address - Zip Code:46562-9200
Mailing Address - Country:US
Mailing Address - Phone:574-594-2711
Mailing Address - Fax:
Practice Address - Street 1:526 S FIRST ST
Practice Address - Street 2:
Practice Address - City:PIERCETON
Practice Address - State:IN
Practice Address - Zip Code:46562-9200
Practice Address - Country:US
Practice Address - Phone:574-594-2711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN452180Medicare UPIN