=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154369833
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATED REHABILITATION GROUP, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2006
-----------------------------------------------------
Last Update Date | 12/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4220 132ND ST SE SUITE 101
-----------------------------------------------------
City | MILL CREEK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98012-8999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-316-8046
-----------------------------------------------------
Fax | 425-659-7449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4220 132ND ST SE SUITE101
-----------------------------------------------------
City | MILL CREEK
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98012-8999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-316-8046
-----------------------------------------------------
Fax | 425-338-9637
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | MICHAEL SHANNON O'KELLEY
-----------------------------------------------------
Credential | MPT
-----------------------------------------------------
Telephone | 425-316-8046
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225XH1200X
-----------------------------------------------------
Taxonomy Name | Hand Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------