Basic Information
| Provider Information | |||||||||
| NPI: | 1700838406 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MORTENSEN AUDIOLOGY CLINICS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SONUS SF 0001 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 CHESHIRE PKWY N | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554464103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885100766 | ||||||||
| FaxNumber: | 7632684017 | ||||||||
| Practice Location | |||||||||
| Address1: | 2255 S 108TH ST | ||||||||
| Address2: | |||||||||
| City: | WEST ALLIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532271107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147744200 | ||||||||
| FaxNumber: | 4147746828 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 03/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | MORTENSEN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/AUDIOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 4147744200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | AU.D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
No ID Information.