Basic Information
| Provider Information | |||||||||
| NPI: | 1255885265 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORTENSON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 43RD AVE | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612658401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097432070 | ||||||||
| FaxNumber: | 3097432073 | ||||||||
| Practice Location | |||||||||
| Address1: | 1905 INGERSOLL AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503093305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5153692306 | ||||||||
| FaxNumber: | 5153692307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2016 | ||||||||
| LastUpdateDate: | 08/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 082456 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.