Healthcare Provider Details

I. General information

NPI: 1619406733
Provider Name (Legal Business Name): COBALT REHABILITATION HOSPITAL FARGO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4671 38TH STREET S
FARGO ND
58104
US

IV. Provider business mailing address

650 BEEBALM LN STE 220
GARLAND TX
75040-2955
US

V. Phone/Fax

Practice location:
  • Phone: 972-330-5870
  • Fax:
Mailing address:
  • Phone: 972-414-6064
  • Fax: 972-414-0078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number
License Number State

VIII. Authorized Official

Name: ERIC HENDRICKSON
Title or Position: REIMBURSEMENT DIRECTOR
Credential:
Phone: 972-414-6064