Provider Demographics
NPI:1528157575
Name:MORTENSEN, RONALD GEORGE (QMRP/TRS)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:GEORGE
Last Name:MORTENSEN
Suffix:
Gender:M
Credentials:QMRP/TRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1367 N 550 E
Mailing Address - Street 2:
Mailing Address - City:NEPHI
Mailing Address - State:UT
Mailing Address - Zip Code:84648-2213
Mailing Address - Country:US
Mailing Address - Phone:435-623-0140
Mailing Address - Fax:435-623-2627
Practice Address - Street 1:1367 N 550 E
Practice Address - Street 2:
Practice Address - City:NEPHI
Practice Address - State:UT
Practice Address - Zip Code:84648-2213
Practice Address - Country:US
Practice Address - Phone:435-623-0140
Practice Address - Fax:435-623-2627
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7830935171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator