Provider Demographics
NPI:1245361591
Name:SHATTUCK REHABILITATION SERVICES
Entity type:Organization
Organization Name:SHATTUCK REHABILITATION SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:SHATTUCK
Authorized Official - Suffix:
Authorized Official - Credentials:OTR L
Authorized Official - Phone:562-430-8700
Mailing Address - Street 1:4772 KATELLA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-2681
Mailing Address - Country:US
Mailing Address - Phone:562-430-8700
Mailing Address - Fax:562-430-8760
Practice Address - Street 1:4772 KATELLA AVE STE 100
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-2681
Practice Address - Country:US
Practice Address - Phone:562-430-8700
Practice Address - Fax:562-430-8760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAA358119225X00000X, 225XE1200X, 225XH1200X
CA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No225XE1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistErgonomicsGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ07888ZOtherBLUE SHIELD GROUP
CA205696000OtherDEPT OF LABOR ACS
CA08127ADOCOtherADOC ID
CA08127ADOCOtherADOC ID
CA5297550001Medicare NSC