Basic Information
| Provider Information | |||||||||
| NPI: | 1245361591 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHATTUCK REHABILITATION SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALING HANDS THERAPY & WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4772 KATELLA AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOS ALAMITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907202681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624308700 | ||||||||
| FaxNumber: | 5624308760 | ||||||||
| Practice Location | |||||||||
| Address1: | 4772 KATELLA AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOS ALAMITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907202681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624308700 | ||||||||
| FaxNumber: | 5624308760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 02/19/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHATTUCK | ||||||||
| AuthorizedOfficialFirstName: | JEANETTE | ||||||||
| AuthorizedOfficialMiddleName: | LOUISE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5624308700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OTR L | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | AA358119 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225XE1200X | AA358119 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Ergonomics | 335E00000X | CA | N | Suppliers | Prosthetic/Orthotic Supplier | 225XH1200X | AA358119 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | ZZZ07888Z | 01 | CA | BLUE SHIELD GROUP | OTHER | 205696000 | 01 | CA | DEPT OF LABOR ACS | OTHER | 08127ADOC | 01 | CA | ADOC ID | OTHER |