Provider Demographics
NPI:1548294168
Name:INTEGRATED REHABILITATION GROUP, PC
Entity type:Organization
Organization Name:INTEGRATED REHABILITATION GROUP, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SHANNON
Authorized Official - Last Name:O'KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:425-316-8046
Mailing Address - Street 1:4220 132ND ST SE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-8999
Mailing Address - Country:US
Mailing Address - Phone:425-316-8046
Mailing Address - Fax:425-338-9637
Practice Address - Street 1:150 126TH ST
Practice Address - Street 2:
Practice Address - City:OROFINO
Practice Address - State:ID
Practice Address - Zip Code:83544-9386
Practice Address - Country:US
Practice Address - Phone:208-476-7105
Practice Address - Fax:208-476-7233
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATED REHABILITATION GROUP, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-10
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1220261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA10022782OtherREGENCE BLUE SHIELD OF ID
WAT9057OtherBLUE CROSS OF ID
WACJ3511OtherRAILROAD MEDICARE
WA3791726-06OtherOWCP
WA807710200Medicaid
WA0129413OtherDEPT. OF LABOR & INDUSTRY
WAT9057OtherBLUE CROSS OF ID