1366488074 NPI number — INTEGRATED REHABILITATION GROUP, PC

Table of content: (NPI 1366488074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366488074 NPI number — INTEGRATED REHABILITATION GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATED REHABILITATION GROUP, PC
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:
IRG PHYSICAL THERAPY - SILVER LAKE
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:
1366488074
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4220 132ND ST SE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
MILL CREEK
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98012-8999
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-357-9380
Provider Business Mailing Address Fax Number:
425-357-9382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10207 19TH AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98208-4257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-337-3166
Provider Business Practice Location Address Fax Number:
425-338-4596
Provider Enumeration Date:
06/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
O'KELLEY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
SHANNON
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
425-316-8046

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7083322 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8928202 . This is a "L&I CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0130583 . This is a "DEPT. OF LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 9055039 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3791726-07 . This is a "OWCP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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