Basic Information
| Provider Information | |||||||||
| NPI: | 1043523533 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMERE REHAB LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MACKENZIE PLACE FC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25117 SW PARKWAY AVE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | WILSONVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970709697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035703665 | ||||||||
| FaxNumber: | 5035709155 | ||||||||
| Practice Location | |||||||||
| Address1: | 4750 PLEASANT OAK DR | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805253737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702071939 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2010 | ||||||||
| LastUpdateDate: | 02/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | CANTRELL | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OUTPATIENT | ||||||||
| AuthorizedOfficialTelephone: | 3609018111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | COA104421 | 01 | CO | PTAN | OTHER |