NPIMap

Organization Active NPI

Professional Rehabilitation Center Inc

Doing business as Pro Rehab Center, Inc

  • Physical Therapist
  • Fargo, ND
National Provider Identifier
1215014105
Registry record updated Oct 29, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
Legal business name
PROFESSIONAL REHABILITATION CENTER INC
Doing business as
Pro Rehab Center, Inc
Practice address
4450 31St Ave S Ste 104
Fargo, ND 58104-4557
Phone
(701) 451-9417
Fax
(701) 298-0066
NPI assigned
Nov 1, 2006
Last updated
Oct 29, 2019By the provider in NPPES
Organization subpart
Yes
Parent organization
PROFESSIONAL REHABILITATION CENTER, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 29, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Tina D Fonder
Title
Office Manager
Phone
(701) 451-9417

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapist 225100000X ND Primary
Occupational Therapist 225X00000X ND

Addresses

Primary practice location

4450 31St Ave S Ste 104
Fargo, ND 58104-4557

Mailing address

4450 31St Ave S Ste 104
Fargo, ND 58104-4557
Phone (701) 451-9417

Other identifiers 6

IdentifierTypeStateIssuer
552323100MedicaidMN
53170MedicaidND
O18T6PROtherMNBLUE CROSS BLUE SHIELD MN
5517001OtherNDBLUE CROSS BLUE SHIELD ND
018T6PROtherMNBLUE PLUS OF MINNESOTA
53165MedicaidND

Other names 1

  • Pro Rehab Center, Inc Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ND

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20041006001028 ND Part B Supplier - Clinic/Group Practice 5193784080 Receives reassigned benefits from 13 practitioners
3 other NPIs on this enrollment
Practice locations: Fargo, ND

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Part of
Professional Rehabilitation

Locations

3105 Broadway N
Ste 7
Fargo, ND 58102
Phone (701) 451-9417

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1162339200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1572307200000",
    "number": "1215014105",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4450 31ST AVE S STE 104",
            "city": "FARGO",
            "state": "ND",
            "postal_code": "581044557",
            "telephone_number": "701-451-9417",
            "fax_number": "701-298-0066"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4450 31ST AVE S STE 104",
            "city": "FARGO",
            "state": "ND",
            "postal_code": "581044557",
            "telephone_number": "701-451-9417",
            "fax_number": "701-298-0066"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROFESSIONAL REHABILITATION CENTER INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROFESSIONAL REHABILITATION CENTER, INC",
        "enumeration_date": "2006-11-01",
        "last_updated": "2019-10-29",
        "status": "A",
        "authorized_official_last_name": "FONDER",
        "authorized_official_first_name": "TINA",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "701-451-9417",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "ND",
            "license": null,
            "primary": true
        },
        {
            "code": "225X00000X",
            "taxonomy_group": "",
            "desc": "Occupational Therapist",
            "state": "ND",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "552323100",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "53170",
            "state": "ND"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD MN",
            "identifier": "O18T6PR",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD ND",
            "identifier": "5517001",
            "state": "ND"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE PLUS OF MINNESOTA",
            "identifier": "018T6PR",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "53165",
            "state": "ND"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Pro Rehab Center, Inc",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Pro Rehab Center, Inc",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fargo, ND

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 29, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.