Basic Information
Provider Information
NPI: 1639513419
EntityType: 2
ReplacementNPI:  
OrganizationName: INTEGRATED REHABILITATION GROUP PC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: GATEWAY PHYSICAL & HAND THERAPY
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4220 132ND ST SE
Address2: SUITE 101
City: MILL CREEK
State: WA
PostalCode: 980128999
CountryCode: US
TelephoneNumber: 4253579380
FaxNumber: 4253579380
Practice Location
Address1: 4220 132ND ST SE
Address2: SUITE 101
City: MILL CREEK
State: WA
PostalCode: 980128994
CountryCode: US
TelephoneNumber: 4253168046
FaxNumber: 4253389637
Other Information
ProviderEnumerationDate: 04/23/2013
LastUpdateDate: 11/03/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: OKELLEY
AuthorizedOfficialFirstName: MICHAEL
AuthorizedOfficialMiddleName: SHANNON
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 4253168046
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: INTEGRATED REHABILITATION GROUP PC
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MPT
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QR0401X WAY Ambulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)

No ID Information.


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