1548294168 NPI number — INTEGRATED REHABILITATION GROUP, PC

Table of content: (NPI 1548294168)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548294168 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:
RIVERSIDE PHYSICAL THERAPY
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:
1548294168
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:
425-316-8046
Provider Business Mailing Address Fax Number:
425-338-9637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 126TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OROFINO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83544-9386
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-476-7105
Provider Business Practice Location Address Fax Number:
208-476-7233
Provider Enumeration Date:
07/10/2006

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 , with the licence number:  PT-1220 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10022782 . This is a "REGENCE BLUE SHIELD OF ID" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: T9057 . This is a "BLUE CROSS OF ID" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: CJ3511 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 3791726-06 . This is a "OWCP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 807710200 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0129413 . This is a "DEPT. OF LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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