1437669116 NPI number — PREMERE REHAB, LLC

Table of content: (NPI 1437669116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437669116 NPI number — PREMERE REHAB, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMERE REHAB, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
INFINITY REHAB
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437669116
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15727 NE RUSSELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97230-8222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-252-9361
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/06/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CANTRELL
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
Authorized Official Title or Position:
REGIONAL DIRECTOR OF OUTPATIENT OPS
Authorized Official Telephone Number:
360-901-8111

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)