Healthcare Provider Details

I. General information

NPI: 1245361591
Provider Name (Legal Business Name): SHATTUCK REHABILITATION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 02/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4772 KATELLA AVE STE 100
LOS ALAMITOS CA
90720-2681
US

IV. Provider business mailing address

4772 KATELLA AVE STE 100
LOS ALAMITOS CA
90720-2681
US

V. Phone/Fax

Practice location:
  • Phone: 562-430-8700
  • Fax: 562-430-8760
Mailing address:
  • Phone: 562-430-8700
  • Fax: 562-430-8760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberAA358119
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225XE1200X
TaxonomyErgonomics Occupational Therapist
License NumberAA358119
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberAA358119
License Number StateCA

VIII. Authorized Official

Name: JEANETTE LOUISE SHATTUCK
Title or Position: PRESIDENT
Credential: OTR L
Phone: 562-430-8700