Provider Demographics
NPI:1326460528
Name:PROFESSIONAL REHABILITATION CENTER
Entity Type:Organization
Organization Name:PROFESSIONAL REHABILITATION CENTER
Other - Org Name:PROREHAB CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUMGARTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-451-9417
Mailing Address - Street 1:1711 GOLD DR S
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6416
Mailing Address - Country:US
Mailing Address - Phone:701-451-9417
Mailing Address - Fax:701-298-0066
Practice Address - Street 1:3105 BROADWAY N
Practice Address - Street 2:SUITE 7
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-1454
Practice Address - Country:US
Practice Address - Phone:701-451-9417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty