Healthcare Provider Details

I. General information

NPI: 1588890891
Provider Name (Legal Business Name): SOUTHEAST SPINE AND REHAB CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2009
Last Update Date: 06/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 E MOODY AVE
KNOXVILLE TN
37920-4203
US

IV. Provider business mailing address

209 E MOODY AVE
KNOXVILLE TN
37920-4203
US

V. Phone/Fax

Practice location:
  • Phone: 865-577-5757
  • Fax:
Mailing address:
  • Phone: 865-577-5757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC0000002320
License Number StateTN

VIII. Authorized Official

Name: DR. GREG KOMESHAK
Title or Position: OWNER
Credential: D.C.
Phone: 865-577-5757