Basic Information
| Provider Information | |||||||||
| NPI: | 1568488112 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED REHABILITATION GROUP, PC | ||||||||
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| OtherOrganizationName: | SOUTH SOUND PHYSICAL & HAND THERAPY - WEST OLY | ||||||||
| 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: | 1651 COOPER POINT RD SW | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985021178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609561100 | ||||||||
| FaxNumber: | 3609561113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 11/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | OKELLEY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4253579380 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 225XH1200X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 3583413-03 | 01 | WA | OWCP | OTHER |