Provider Demographics
NPI:1629149612
Name:MORTENSON, DALE E (DC)
Entity Type:Individual
Prefix:MR
First Name:DALE
Middle Name:E
Last Name:MORTENSON
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:POB 1960
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-6960
Mailing Address - Country:US
Mailing Address - Phone:850-265-6163
Mailing Address - Fax:850-265-4059
Practice Address - Street 1:1101 OHIO AVE
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-2554
Practice Address - Country:US
Practice Address - Phone:850-265-6163
Practice Address - Fax:850-265-4059
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH4624111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL70497OtherBCBS
FL70497Medicare ID - Type Unspecified
FL70497OtherBCBS