Basic Information
| Provider Information | |||||||||
| NPI: | 1972537926 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED REHABILITATION GROUP PC | ||||||||
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| OtherOrganizationName: | EDMONDS HAND THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4220 132ND ST SE | ||||||||
| Address2: | SUITE101 | ||||||||
| City: | MILL CREEK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980128999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253168046 | ||||||||
| FaxNumber: | 4253389637 | ||||||||
| Practice Location | |||||||||
| Address1: | 7907 212TH ST SW | ||||||||
| Address2: | SUITE 219 | ||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256732673 | ||||||||
| FaxNumber: | 4256732863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 11/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | O'KELLEY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | SHANNON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4253168046 | ||||||||
| 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 | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 225XH1200X | OT00003076 | WA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | 3791726-02 | 01 | WA | OWCP | OTHER | 0174880 | 01 | WA | DEPT. OF LABOR & INDUSTRY | OTHER | 7682230 | 05 | WA | MEDICAID | 8933872 | 01 | WA | L&I CRIME VICTIMS | OTHER | 9055039 | 05 | WA | MEDICAID |