Healthcare Provider Details

I. General information

NPI: 1114703899
Provider Name (Legal Business Name): PREMERE REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2023
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 WALNUT AVE
FREMONT CA
94538-2275
US

IV. Provider business mailing address

8100 SW NYBERG ST STE 200
TUALATIN OR
97062-8437
US

V. Phone/Fax

Practice location:
  • Phone: 510-505-0555
  • Fax:
Mailing address:
  • Phone: 503-570-3665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: TAMMY MCCOY
Title or Position: CREDENTIALING SPECIALT
Credential:
Phone: 971-224-2841