Provider Demographics
NPI:1992921985
Name:MORTENSON, KORI
Entity type:Individual
Prefix:DR
First Name:KORI
Middle Name:
Last Name:MORTENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 E 42ND ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-3153
Mailing Address - Country:US
Mailing Address - Phone:612-721-8926
Mailing Address - Fax:
Practice Address - Street 1:3025 E 42ND ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-3153
Practice Address - Country:US
Practice Address - Phone:612-721-8926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3737111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
09S83MOOtherBLUE CROSS BLUE SHIELD
09S83MOOtherBLUE CROSS BLUE SHIELD