Healthcare Provider Details

I. General information

NPI: 1982114666
Provider Name (Legal Business Name): PREMERE REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2017
Last Update Date: 10/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 NE CLEVELAND AVE
GRESHAM OR
97030-4283
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 503-465-1404
  • Fax:
Mailing address:
  • Phone: 971-224-2040
  • Fax: 888-795-0947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LAURA CANTRELL
Title or Position: REGIONAL DIRECTOR OF OUTPATIENT OPS
Credential: PT
Phone: 360-901-8111