Provider Demographics
NPI:1316971377
Name:INTEGRATED REHABILITATION GROUP INC
Entity type:Organization
Organization Name:INTEGRATED REHABILITATION GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
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:425-337-9556
Mailing Address - Street 1:1519 132ND ST SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-7203
Mailing Address - Country:US
Mailing Address - Phone:425-330-0633
Mailing Address - Fax:425-338-9637
Practice Address - Street 1:22500 NE MARKETPLACE DR
Practice Address - Street 2:SUITE 204
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98053-2033
Practice Address - Country:US
Practice Address - Phone:425-836-1034
Practice Address - Fax:425-836-1037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225XH1200X, 225700000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1182780006OtherDME
WA0191251OtherDEPT. OF LABOR & INDUSTRY
WA9055039Medicaid
WA7083322Medicaid
WA7682230Medicaid
WA8930484OtherL&I CRIME VICTIMS
WAG8850395Medicare PIN