Provider Demographics
NPI:1770541203
Name:MARIETTA CENTER FOR REHABILITATION INC
Entity type:Organization
Organization Name:MARIETTA CENTER FOR REHABILITATION INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MATTSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:770-424-6787
Mailing Address - Street 1:631 CAMPBELL HILL ST NW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1301
Mailing Address - Country:US
Mailing Address - Phone:770-424-6787
Mailing Address - Fax:770-426-7925
Practice Address - Street 1:631 CAMPBELL HILL ST NW
Practice Address - Street 2:SUITE 200
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1301
Practice Address - Country:US
Practice Address - Phone:770-424-6787
Practice Address - Fax:770-426-7925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116636Medicare Oscar/Certification