Healthcare Provider Details

I. General information

NPI: 1366710659
Provider Name (Legal Business Name): PREMERE REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 E SAN MIGUEL ST
COLORADO SPRINGS CO
80909-3427
US

IV. Provider business mailing address

25117 SW PARKWAY AVE SUITE D
WILSONVILLE OR
97070-9697
US

V. Phone/Fax

Practice location:
  • Phone: 719-597-4112
  • Fax:
Mailing address:
  • Phone: 888-757-3422
  • 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: LAURA CANTRELL
Title or Position: DIRECTOR OF OUTPATIENT
Credential:
Phone: 360-901-8111