Provider Demographics
NPI:1669546511
Name:MORTENSEN, MERRITT (DC)
Entity type:Individual
Prefix:
First Name:MERRITT
Middle Name:
Last Name:MORTENSEN
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 1:1395 E WARNER RD STE 102
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3147
Mailing Address - Country:US
Mailing Address - Phone:480-635-8228
Mailing Address - Fax:480-635-9972
Practice Address - Street 1:1395 E WARNER RD STE 102
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3147
Practice Address - Country:US
Practice Address - Phone:480-635-8228
Practice Address - Fax:480-635-9972
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6047111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ79398Medicare PIN
AZU84940Medicare UPIN
AZ79400Medicare PIN