Healthcare Provider Details

I. General information

NPI: 1669546511
Provider Name (Legal Business Name): MERRITT MORTENSEN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 E WARNER RD STE 102
GILBERT AZ
85296-3147
US

IV. Provider business mailing address

1395 E WARNER RD STE 102
GILBERT AZ
85296-3147
US

V. Phone/Fax

Practice location:
  • Phone: 480-635-8228
  • Fax: 480-635-9972
Mailing address:
  • Phone: 480-635-8228
  • Fax: 480-635-9972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6047
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: