1154369833 NPI number — INTEGRATED REHABILITATION GROUP, PC

Table of content: (NPI 1154369833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154369833 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:
Provider Other Organization Name Type Code:
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:
1154369833
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:
SUITE101
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:
425-316-8046
Provider Business Mailing Address Fax Number:
425-338-9637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4220 132ND ST SE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MILL CREEK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98012-8999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-316-8046
Provider Business Practice Location Address Fax Number:
425-659-7449
Provider Enumeration Date:
06/03/2006

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: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XH1200X , registered in the state of WA ; 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: 0112780 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7682230 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8930484 . This is a "L&I CRIME VICTIMS" 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: IN5136 . This is a "REGENCE BLUESHIELD GRP #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: CJ2801 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7083322 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3791726-00 . This is a "OWCP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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