Provider Demographics
NPI:1689600801
Name:PREMIERE REHAB, LLC
Entity Type:Organization
Organization Name:PREMIERE REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHENIN
Authorized Official - Middle Name:KAE
Authorized Official - Last Name:CHESTNUT
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:317-542-7680
Mailing Address - Street 1:9505 E 59TH ST
Mailing Address - Street 2:SUITE B1
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46216-1025
Mailing Address - Country:US
Mailing Address - Phone:317-542-7680
Mailing Address - Fax:317-542-7682
Practice Address - Street 1:9505 E 59TH ST
Practice Address - Street 2:SUITE B1
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46216-1025
Practice Address - Country:US
Practice Address - Phone:317-542-7680
Practice Address - Fax:317-542-7682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN235Z00000X, 261QP2000X
IN31003306A261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Not Answered261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Not Answered261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN234900Medicare ID - Type UnspecifiedFACILITY NUMBER
IN234900AMedicare ID - Type UnspecifiedOCCUPATIONAL THERAPY
IN234900BMedicare ID - Type UnspecifiedPHYSICAL THERAPY