Basic Information
| Provider Information | |||||||||
| NPI: | 1275088924 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED REHABILITATION GROUP, PC | ||||||||
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| OtherOrganizationName: | IRG PHYSICAL & HAND THERAPY BONNEY LAKE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4220 132ND ST SE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MILL CREEK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980128999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253579380 | ||||||||
| FaxNumber: | 4253579382 | ||||||||
| Practice Location | |||||||||
| Address1: | 9411 192ND AVE E | ||||||||
| Address2: | BUILDING D, SUITE E | ||||||||
| City: | BONNEY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983918564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532685105 | ||||||||
| FaxNumber: | 2532583298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2016 | ||||||||
| LastUpdateDate: | 01/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | O'KELLEY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | SHANNON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4253168046 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INTEGRATED REHABILITATION GROUP, PC | ||||||||
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| AuthorizedOfficialCredential: | MPT | ||||||||
| NPICertificationDate: | 01/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.