Basic Information
| Provider Information | |||||||||
| NPI: | 1740222017 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED REHABILITATION GROUP PC | ||||||||
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| OtherOrganizationName: | IRG PHYSICAL & HAND THERAPY- ARLINGTON | ||||||||
| 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: | 7728 204TH ST NE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ARLINGTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982234603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604038250 | ||||||||
| FaxNumber: | 3604030917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 06/11/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | DANIELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4253168046 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INTEGRATED REHABILITATION GROUP PC | ||||||||
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| NPICertificationDate: | 06/11/2020 | ||||||||
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 | 462797001 | 01 | WA | GROUP HEALTH MEDICARE | OTHER | 462797004 | 01 | WA | GROUP HEALTH NON-MEDICARE | OTHER | 0112780 | 01 | WA | DEPT. OF LABOR & INDUSTRY | OTHER | 3791726-01 | 01 | WA | OWCP | OTHER | 650021104 | 01 | WA | RR MEDICARE | OTHER | 7083322 | 05 | WA | MEDICAID | 7682230 | 05 | WA | MEDICAID | 8928203 | 01 | WA | L&I CRIME VICITIMS | OTHER | 9055039 | 05 | WA | MEDICAID |