Provider Demographics
NPI:1952544413
Name:DALE E MORTENSON DC PA
Entity type:Organization
Organization Name:DALE E MORTENSON DC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:E
Authorized Official - Last Name:MORTENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-265-6163
Mailing Address - Street 1:PO BOX 1960
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-6960
Mailing Address - Country:US
Mailing Address - Phone:850-265-6163
Mailing Address - Fax:850-265-4059
Practice Address - Street 1:1101 OHIO AVE
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-2554
Practice Address - Country:US
Practice Address - Phone:850-265-6163
Practice Address - Fax:850-265-4059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-14
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH4624111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT84466Medicare UPIN
FL70497Medicare PIN