1588952402 NPI number — INTEGRATED REHABILITATION GROUP, PC

Table of content: (NPI 1588952402)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588952402 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:
SOUTH SOUND PHYSICAL & HAND THERAPY, PLLC
Provider Other Organization Name Type Code:
4
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:
1588952402
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2020
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:
111 MARKET ST NE
Provider Second Line Business Practice Location Address:
# 108
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98501-1008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-754-7085
Provider Business Practice Location Address Fax Number:
360-754-3671
Provider Enumeration Date:
07/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KELLY
Authorized Official First Name:
DANIELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
425-316-8046

Provider Taxonomy Codes

  • Taxonomy code: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XH1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3583413-00 . This is a "OWCP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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