MEDICARE: MR. DALE E MORTENSON DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CH4624	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	70497	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1629149612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DALE E MORTENSON DC

Provider Business Mailing Address
First Line	:	POB 1960
Second Line	:
City	:	LYNN HAVEN
State	:	FL
Zip	:	32444-6960
Country	:	US
Telephone Number	:	850-265-6163
Fax Number	:	850-265-4059

Provider Business Practice Location Address
First Line	:	1101 OHIO AVE
Second Line	:
City	:	LYNN HAVEN
State	:	FL
Zip	:	32444-2554
Country	:	US
Telephone Number	:	850-265-6163
Fax Number	:	850-265-4059

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	03/18/2015

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Directions to “ MR. DALE E MORTENSON DC” Practice Location

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