Basic Information
| Provider Information | |||||||||
| NPI: | 1548294168 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED REHABILITATION GROUP PC | ||||||||
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| OtherOrganizationName: | RIVERSIDE PHYSICAL THERAPY | ||||||||
| 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: | 4253168046 | ||||||||
| FaxNumber: | 4253389637 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 126TH ST | ||||||||
| Address2: | |||||||||
| City: | OROFINO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835449386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084767105 | ||||||||
| FaxNumber: | 2084767233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 12/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | O'KELLEY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | SHANNON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4253579380 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INTEGRATED REHABILITATION GROUP PC | ||||||||
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| AuthorizedOfficialCredential: | MPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | PT-1220 | ID | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 0129413 | 01 | WA | DEPT. OF LABOR & INDUSTRY | OTHER | CJ3511 | 01 | WA | RAILROAD MEDICARE | OTHER | 3791726-06 | 01 | WA | OWCP | OTHER | 10022782 | 01 | WA | REGENCE BLUE SHIELD OF ID | OTHER | 807710200 | 05 | WA | MEDICAID | T9057 | 01 | WA | BLUE CROSS OF ID | OTHER |