Healthcare Provider Details

I. General information

NPI: 1508018490
Provider Name (Legal Business Name): COMPREHENSIVE REHAB CENTERS OF MN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2008
Last Update Date: 10/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 W LAKE ST
MINNEAPOLIS MN
55408-3119
US

IV. Provider business mailing address

133 W LAKE ST
MINNEAPOLIS MN
55408-3119
US

V. Phone/Fax

Practice location:
  • Phone: 612-823-2020
  • Fax: 612-823-1919
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number4690
License Number StateMN

VIII. Authorized Official

Name: DR. PRESTON FORTHUN
Title or Position: CHIROPRACTOR/ATHLETIC TRAINER
Credential: DC, ATC
Phone: 612-823-2020