Healthcare Provider Details

I. General information

NPI: 1215014105
Provider Name (Legal Business Name): PROFESSIONAL REHABILITATION CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 31ST AVE S STE 104
FARGO ND
58104-4557
US

IV. Provider business mailing address

4450 31ST AVE S STE 104
FARGO ND
58104-4557
US

V. Phone/Fax

Practice location:
  • Phone: 701-451-9417
  • Fax: 701-298-0066
Mailing address:
  • Phone: 701-451-9417
  • Fax: 701-298-0066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateND

VIII. Authorized Official

Name: MS. TINA D FONDER
Title or Position: OFFICE MANAGER
Credential:
Phone: 701-451-9417