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General NPI Number Information
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NPI Number | 1952544413
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Entity Type | Organization
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Legal Business Name | DALE E MORTENSON DC PA
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Dates
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Enumeration Date | 04/14/2009
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Last Update Date | 05/20/2009
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Provider Practice Location Address
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Address Line | 1101 OHIO AVE
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City | LYNN HAVEN
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State | FL
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Zip | 32444-2554
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Country | US
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Telephone | 850-265-6163
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Fax | 850-265-4059
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Provider Business Mailing Address
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Address Line | PO BOX 1960
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City | LYNN HAVEN
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State | FL
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Zip | 32444-6960
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Country | US
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Telephone | 850-265-6163
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Fax | 850-265-4059
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Authorized Official
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Title or Position | PRESIDENT
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Name | DALE E. MORTENSON
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Credential | D.C.
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Telephone | 850-265-6163
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH4624
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License Number State | FL
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