Provider Demographics
NPI:1629326376
Name:AT-HOME PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:AT-HOME PHYSICAL THERAPY, PC
Other - Org Name:REHAB 4 LIFE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:STROH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:701-293-7294
Mailing Address - Street 1:4622 40TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4394
Mailing Address - Country:US
Mailing Address - Phone:701-293-7294
Mailing Address - Fax:701-282-9738
Practice Address - Street 1:1420 9TH ST S
Practice Address - Street 2:SUITE 409
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-3381
Practice Address - Country:US
Practice Address - Phone:701-293-7294
Practice Address - Fax:701-282-9738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND0962225100000X
ND924225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty