Provider Demographics
NPI:1154369833
Name:INTEGRATED REHABILITATION GROUP, PC
Entity type:Organization
Organization Name:INTEGRATED REHABILITATION GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SHANNON
Authorized Official - Last Name:O'KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:425-316-8046
Mailing Address - Street 1:4220 132ND ST SE
Mailing Address - Street 2:SUITE101
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-8999
Mailing Address - Country:US
Mailing Address - Phone:425-316-8046
Mailing Address - Fax:425-338-9637
Practice Address - Street 1:4220 132ND ST SE
Practice Address - Street 2:SUITE 101
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-8999
Practice Address - Country:US
Practice Address - Phone:425-316-8046
Practice Address - Fax:425-659-7449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X, 261QP2000X
WA225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0112780OtherL&I
WA7682230Medicaid
WA8930484OtherL&I CRIME VICTIMS
WA9055039Medicaid
WAIN5136OtherREGENCE BLUESHIELD GRP #
WACJ2801OtherRAILROAD MEDICARE
WA7083322Medicaid
WA3791726-00OtherOWCP
ID1653219Medicare PIN
WA8930484OtherL&I CRIME VICTIMS
WA7682230Medicaid