Healthcare Provider Details

I. General information

NPI: 1902096167
Provider Name (Legal Business Name): PRIME REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8690 EAGLE CREEK PKWY
SAVAGE MN
55378-1284
US

IV. Provider business mailing address

8690 EAGLE CREEK PKWY
SAVAGE MN
55378-1284
US

V. Phone/Fax

Practice location:
  • Phone: 952-412-6207
  • Fax: 952-487-2829
Mailing address:
  • Phone: 952-412-6207
  • Fax: 952-487-2829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY LEONARD KALLBERG
Title or Position: PRESIDENT
Credential: PT
Phone: 952-412-6207