Healthcare Provider Details

I. General information

NPI: 1245839547
Provider Name (Legal Business Name): PREMERE REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 10/19/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 E OVATION PL
WASHINGTON UT
84780
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 435-429-0000
  • Fax: 866-728-9636
Mailing address:
  • Phone: 971-255-4079
  • 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 OF OUTPATIENT OPS
Credential: PT
Phone: 360-901-8111