Provider Demographics
NPI:1215014105
Name:PROFESSIONAL REHABILITATION CENTER INC
Entity Type:Organization
Organization Name:PROFESSIONAL REHABILITATION CENTER INC
Other - Org Name:PRO REHAB CENTER, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:D
Authorized Official - Last Name:FONDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-451-9417
Mailing Address - Street 1:4450 31ST AVE S STE 104
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4557
Mailing Address - Country:US
Mailing Address - Phone:701-451-9417
Mailing Address - Fax:701-298-0066
Practice Address - Street 1:4450 31ST AVE S STE 104
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-4557
Practice Address - Country:US
Practice Address - Phone:701-451-9417
Practice Address - Fax:701-298-0066
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROFESSIONAL REHABILITATION CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-01
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND225100000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN018T6PROtherBLUE PLUS OF MINNESOTA
ND53165Medicaid
MN552323100Medicaid
ND53170Medicaid
MNO18T6PROtherBLUE CROSS BLUE SHIELD MN
ND5517001OtherBLUE CROSS BLUE SHIELD ND
MN018T6PROtherBLUE PLUS OF MINNESOTA
MN552323100Medicaid