Basic Information
Provider Information | |||||||||
NPI: | 1528705845 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INTEGRATED REHABILITATION GROUP, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4220 132ND ST SE STE 101 | ||||||||
Address2: |   | ||||||||
City: | MILL CREEK | ||||||||
State: | WA | ||||||||
PostalCode: | 980128999 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4253168046 | ||||||||
FaxNumber: | 4253579382 | ||||||||
Practice Location | |||||||||
Address1: | 1332 COLBY AVE | ||||||||
Address2: |   | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982011618 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4254704040 | ||||||||
FaxNumber: | 4254929355 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2022 | ||||||||
LastUpdateDate: | 05/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OKELLEY | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PT | ||||||||
AuthorizedOfficialTelephone: | 4253579380 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.