Provider Demographics
NPI:1902096167
Name:PRIME REHABILITATION LLC
Entity Type:Organization
Organization Name:PRIME REHABILITATION LLC
Other - Org Name:ACCUA ADVANCED REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:KALLBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:952-412-6207
Mailing Address - Street 1:8690 EAGLE CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-1284
Mailing Address - Country:US
Mailing Address - Phone:952-412-6207
Mailing Address - Fax:952-487-2829
Practice Address - Street 1:8690 EAGLE CREEK PKWY
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-1284
Practice Address - Country:US
Practice Address - Phone:952-412-6207
Practice Address - Fax:952-487-2829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
160D2KAOtherBLUECROSS BLUESHIELD OF MINNESOTA
MN600088600Medicaid
160D2KAOtherBLUECROSS BLUESHIELD OF MINNESOTA