Provider Demographics
NPI:1598829327
Name:PREMIER BACK REHABILITATION CENTER, PC
Entity Type:Organization
Organization Name:PREMIER BACK REHABILITATION CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERE
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:719-544-1161
Mailing Address - Street 1:1515 FORTINO BLVD STE 150
Mailing Address - Street 2:STE 150
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1976
Mailing Address - Country:US
Mailing Address - Phone:719-544-1161
Mailing Address - Fax:719-544-1128
Practice Address - Street 1:1515 FORTINO BLVD STE 150
Practice Address - Street 2:STE 150
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1976
Practice Address - Country:US
Practice Address - Phone:719-544-1161
Practice Address - Fax:719-544-1128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic TraumaGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO5277360001Medicare NSC
COC531868Medicare PIN
CODD3094Medicare PIN