Provider Demographics
NPI:1649667858
Name:MORTENSON, BRUCE
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:MORTENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 2ND ST
Mailing Address - Street 2:
Mailing Address - City:WAUBUN
Mailing Address - State:MN
Mailing Address - Zip Code:56589-4022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1205 2ND ST
Practice Address - Street 2:
Practice Address - City:WAUBUN
Practice Address - State:MN
Practice Address - Zip Code:56589-4022
Practice Address - Country:US
Practice Address - Phone:218-261-2016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-26
Last Update Date:2015-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer