Provider Demographics
NPI:1700981230
Name:MORTENSON, MICHAEL DAVID (DC DOCTOR OF CHIROPR)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:MORTENSON
Suffix:
Gender:M
Credentials:DC DOCTOR OF CHIROPR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 134
Mailing Address - Street 2:801 INMAN STREET
Mailing Address - City:HENNING
Mailing Address - State:MN
Mailing Address - Zip Code:56551
Mailing Address - Country:US
Mailing Address - Phone:218-548-2447
Mailing Address - Fax:218-548-2448
Practice Address - Street 1:801 INMAN STREET
Practice Address - Street 2:
Practice Address - City:HENNING
Practice Address - State:MN
Practice Address - Zip Code:56551
Practice Address - Country:US
Practice Address - Phone:218-548-2447
Practice Address - Fax:218-548-2448
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3941111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN616787OtherCHIROCARE MEDICA
MN36D46HEOtherBCBS
MN36D45M0OtherBCBS
MN36D45M0OtherBCBS