Provider Demographics
NPI:1427386200
Name:MOSSY CREEK REHAB
Entity Type:Organization
Organization Name:MOSSY CREEK REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MATIJEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-246-8090
Mailing Address - Street 1:1405 S SIZER AVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-2436
Mailing Address - Country:US
Mailing Address - Phone:865-246-8090
Mailing Address - Fax:
Practice Address - Street 1:1405 S SIZER AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-2436
Practice Address - Country:US
Practice Address - Phone:865-246-8090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-06
Last Update Date:2009-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000001151225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty