Provider Demographics
NPI:1780963355
Name:CENTER FOR PRIMARY CARE AND REHABILITATION, PA
Entity type:Organization
Organization Name:CENTER FOR PRIMARY CARE AND REHABILITATION, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:LEV
Authorized Official - Last Name:POLUKHIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:651-789-8022
Mailing Address - Street 1:3006 FRANK ST
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-5501
Mailing Address - Country:US
Mailing Address - Phone:651-789-8022
Mailing Address - Fax:651-789-8028
Practice Address - Street 1:880 BLUE GENTIAN RD STE 165
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-1772
Practice Address - Country:US
Practice Address - Phone:651-789-8022
Practice Address - Fax:651-789-8028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45600225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty