Provider Demographics
NPI:1932566726
Name:RYAN J. MORTENSEN, INC
Entity Type:Organization
Organization Name:RYAN J. MORTENSEN, INC
Other - Org Name:DISTRICT VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-495-4833
Mailing Address - Street 1:11506 S DISTRICT DR STE 400
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-5769
Mailing Address - Country:US
Mailing Address - Phone:801-495-4833
Mailing Address - Fax:
Practice Address - Street 1:11506 S DISTRICT DR STE 400
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5769
Practice Address - Country:US
Practice Address - Phone:801-495-4833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5898711-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528496527001Medicaid
UT000062564Medicare PIN