MEDICARE: PREMERE REHAB LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	225X00000X	Occupational Therapist
2	235Z00000X	Speech-Language Pathologist
3	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	COA104421	OTHER	CO	PTAN

General Provider Information

NPI Number	:	1043523533
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMERE REHAB LLC

Provider Business Mailing Address
First Line	:	25117 SW PARKWAY AVE
Second Line	:	SUITE D
City	:	WILSONVILLE
State	:	OR
Zip	:	97070-9697
Country	:	US
Telephone Number	:	503-570-3665
Fax Number	:	503-570-9155

Provider Business Practice Location Address
First Line	:	4750 PLEASANT OAK DR
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-3737
Country	:	US
Telephone Number	:	970-207-1939
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OUTPATIENT
Name	:	LAURA A CANTRELL
Credential	:	PT
Telephone Number	:	360-901-8111

Provider Enumeration Date	:	07/26/2010
Last Update Date	:	02/20/2012

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Directions to “PREMERE REHAB LLC ” Practice Location

Language	Start Address	Practice Location

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