Provider Demographics
NPI:1871823005
Name:PREMERE REHAB LLC
Entity Type:Organization
Organization Name:PREMERE REHAB LLC
Other - Org Name:ROCK OF AGES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OUTPATIENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-901-8111
Mailing Address - Street 1:25117 SW PARKWAY
Mailing Address - Street 2:SUITE D
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070
Mailing Address - Country:US
Mailing Address - Phone:888-757-3422
Mailing Address - Fax:877-282-1880
Practice Address - Street 1:15600 SW ROCK OF AGES RD
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-8531
Practice Address - Country:US
Practice Address - Phone:503-472-6212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-11
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR159930Medicare PIN