Healthcare Provider Details

I. General information

NPI: 1679258974
Provider Name (Legal Business Name): PREMERE REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 06/15/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 RIO GRANDE
CARBONDALE CO
81623-1700
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 970-329-9574
  • Fax:
Mailing address:
  • Phone: 35-703-6655
  • Fax: 503-570-9155

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 SPECIALIST
Credential:
Phone: 971-224-2841