Healthcare Provider Details

I. General information

NPI: 1669914289
Provider Name (Legal Business Name): PREMERE REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2016
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4002 TETON TRCE HERITAGE AT NORTHERN HILLS
SIOUX CITY IA
51104-4338
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 712-202-5330
  • Fax:
Mailing address:
  • Phone: 971-224-2040
  • Fax: 888-795-0947

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: REGIONAL DIRECTOR OUTPATIENT CLINIC
Credential: PT
Phone: 360-901-8111