Basic Information
| Provider Information | |||||||||
| NPI: | 1316971377 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED REHABILITATION GROUP INC | ||||||||
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| OtherOrganizationName: | REDMOND RIDGE PHYSICAL & HAND THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1519 132ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982087203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253300633 | ||||||||
| FaxNumber: | 4253389637 | ||||||||
| Practice Location | |||||||||
| Address1: | 22500 NE MARKETPLACE DR | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | REDMOND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980532033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258361034 | ||||||||
| FaxNumber: | 4258361037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 10/04/2007 | ||||||||
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| AuthorizedOfficialLastName: | O'KELLEY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | SHANNON | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 4253379556 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225700000X | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 1182780006 | 01 | WA | DME | OTHER | 0191251 | 01 | WA | DEPT. OF LABOR & INDUSTRY | OTHER | 9055039 | 05 | WA | MEDICAID | 7083322 | 05 | WA | MEDICAID | 7682230 | 05 | WA | MEDICAID | 8930484 | 01 | WA | L&I CRIME VICTIMS | OTHER |