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

General Provider Information

NPI Number	:	1669914289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMERE REHAB LLC

Provider Business Mailing Address
First Line	:	25117 SW PARKWAY AVE
Second Line	:	STE D
City	:	WILSONVILLE
State	:	OR
Zip	:	97070-9697
Country	:	US
Telephone Number	:	971-224-2040
Fax Number	:	888-795-0947

Provider Business Practice Location Address
First Line	:	4002 TETON TRCE
Second Line	:	HERITAGE AT NORTHERN HILLS
City	:	SIOUX CITY
State	:	IA
Zip	:	51104-4338
Country	:	US
Telephone Number	:	712-202-5330
Fax Number	:

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

Provider Enumeration Date	:	11/14/2016
Last Update Date	:	11/14/2016

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Directions to “PREMERE REHAB LLC ” Practice Location

Language	Start Address	Practice Location

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