Healthcare Provider Details

I. General information

NPI: 1700838406
Provider Name (Legal Business Name): MORTENSEN AUDIOLOGY CLINICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 03/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 S 108TH ST
WEST ALLIS WI
53227-1107
US

IV. Provider business mailing address

5000 CHESHIRE PKWY N
PLYMOUTH MN
55446-4103
US

V. Phone/Fax

Practice location:
  • Phone: 414-774-4200
  • Fax: 414-774-6828
Mailing address:
  • Phone: 888-510-0766
  • Fax: 763-268-4017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN A MORTENSEN
Title or Position: OWNER/AUDIOLOGIST
Credential: AU.D
Phone: 414-774-4200