1740222017 NPI number — INTEGRATED REHABILITATION GROUP, PC

Table of content: (NPI 1740222017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740222017 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:
6
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:
1740222017
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:
7728 204TH ST NE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98223-4603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-403-8250
Provider Business Practice Location Address Fax Number:
360-403-0917
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OKELLEY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
425-316-8046

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , registered in the state of WA ; 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: 650021104 . This is a "RR MEDICARE" 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: 3791726-01 . This is a "OWCP" 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: 462797001 . This is a "GROUP HEALTH MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 462797004 . This is a "GROUP HEALTH NON-MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8928203 . This is a "L&I CRIME VICITIMS" 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: 0112780 . 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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