Basic Information
| Provider Information | |||||||||
| NPI: | 1306842547 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIMARY CARE & REHABILITATION CLINICS, INC. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3015 UTAH AVE S | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554263671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529338900 | ||||||||
| FaxNumber: | 9529459536 | ||||||||
| Practice Location | |||||||||
| Address1: | 3015 UTAH AVE S | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554263671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529338900 | ||||||||
| FaxNumber: | 9529459536 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FRID | ||||||||
| AuthorizedOfficialFirstName: | LEON | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9529338900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 3C060TE | 01 | MN | BCBS D.C. PROV # | OTHER | 2M391TE | 01 | MN | BCBS MD PROVIDER # | OTHER | 8B610TE | 01 | MN | BCBS PT PROVIDER # | OTHER |