MEDICARE: DALE E MORTENSON DC PA

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

General Provider Information

NPI Number	:	1952544413
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DALE E MORTENSON DC PA

Provider Business Mailing Address
First Line	:	PO BOX 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	:	PRESIDENT
Name	:	DALE E. MORTENSON
Credential	:	D.C.
Telephone Number	:	850-265-6163

Provider Enumeration Date	:	04/14/2009
Last Update Date	:	05/20/2009

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Directions to “DALE E MORTENSON DC PA ” Practice Location

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