Provider Demographics
NPI:1487830154
Name:MATTHEW K MORTENSEN DC LTD
Entity Type:Organization
Organization Name:MATTHEW K MORTENSEN DC LTD
Other - Org Name:LAKE MEAD CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:702-255-3003
Mailing Address - Street 1:8576 W LAKE MEAD BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-7630
Mailing Address - Country:US
Mailing Address - Phone:702-255-3003
Mailing Address - Fax:702-255-8133
Practice Address - Street 1:8576 W LAKE MEAD BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-7630
Practice Address - Country:US
Practice Address - Phone:702-255-3003
Practice Address - Fax:702-255-8133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-12
Last Update Date:2008-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty