Basic Information
Provider Information | |||||||||
NPI: | 1851343552 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MORTENSEN AUDIOLOGY CLINICS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SONUS SF 0001 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5000 CHESHIRE PKWY N | ||||||||
Address2: |   | ||||||||
City: | PLYMOUTH | ||||||||
State: | MN | ||||||||
PostalCode: | 554464103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8885100766 | ||||||||
FaxNumber: | 7632684017 | ||||||||
Practice Location | |||||||||
Address1: | W186N9523 BANCROFT DR | ||||||||
Address2: |   | ||||||||
City: | MENOMONEE FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 530518009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2625023570 | ||||||||
FaxNumber: | 2625023572 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2006 | ||||||||
LastUpdateDate: | 03/16/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MORTENSEN | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/AUDIOLOGIST | ||||||||
AuthorizedOfficialTelephone: | 4147744200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
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.