Provider Demographics
NPI:1437906096
Name:SHAKE REHABILITATION SERVICES LLC
Entity type:Organization
Organization Name:SHAKE REHABILITATION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BENNETT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-232-2289
Mailing Address - Street 1:4082 WARTHOG HTS
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80916-3402
Mailing Address - Country:US
Mailing Address - Phone:214-232-2289
Mailing Address - Fax:
Practice Address - Street 1:4224 N NEVADA AVE STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-4368
Practice Address - Country:US
Practice Address - Phone:719-900-1817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty