Provider Demographics
NPI:1669673356
Name:RACHEL V MORTENSON OD PC
Entity Type:Organization
Organization Name:RACHEL V MORTENSON OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:MORTENSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:319-283-3628
Mailing Address - Street 1:208 8TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:OELWEIN
Mailing Address - State:IA
Mailing Address - Zip Code:50662-2448
Mailing Address - Country:US
Mailing Address - Phone:319-283-3628
Mailing Address - Fax:
Practice Address - Street 1:208 8TH AVE SE
Practice Address - Street 2:
Practice Address - City:OELWEIN
Practice Address - State:IA
Practice Address - Zip Code:50662-2448
Practice Address - Country:US
Practice Address - Phone:319-283-3628
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02165152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1262402Medicaid
IADC6408OtherPALMETTO GBA-RR MEDICARE
IADC6408OtherPALMETTO GBA-RR MEDICARE
IAI13243Medicare PIN