Provider Demographics
NPI:1093989709
Name:JUST KIDS REHABILITATION SERVICES LLC
Entity Type:Organization
Organization Name:JUST KIDS REHABILITATION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHUTTLEWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:724-971-1021
Mailing Address - Street 1:PO BOX 594
Mailing Address - Street 2:
Mailing Address - City:WAMPUM
Mailing Address - State:PA
Mailing Address - Zip Code:16157-0594
Mailing Address - Country:US
Mailing Address - Phone:724-630-5607
Mailing Address - Fax:
Practice Address - Street 1:1750 NEW BUTLER RD
Practice Address - Street 2:SUITE D
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16101-3184
Practice Address - Country:US
Practice Address - Phone:724-971-1021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT016373225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001961402Medicaid
PA001961402Medicaid