Healthcare Provider Details

I. General information

NPI: 1700953924
Provider Name (Legal Business Name): PREMIER REHAB, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4460 N ILLINOIS ST #5
SWANSEA IL
62226-1899
US

IV. Provider business mailing address

4460 N ILLINOIS ST #5
SWANSEA IL
62226-1899
US

V. Phone/Fax

Practice location:
  • Phone: 618-236-3738
  • Fax: 618-257-3291
Mailing address:
  • Phone: 618-236-3738
  • Fax: 618-257-3291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number StateIL

VIII. Authorized Official

Name: TIMOTHY J BERTELSMAN
Title or Position: PRESIDENT
Credential: DC
Phone: 618-236-3738