Basic Information
| Provider Information | |||||||||
| NPI: | 1023117074 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLEMSON SPORTS MEDICINE AND REHABILITATION, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPORTS PLUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 1844 | ||||||||
| Address2: | |||||||||
| City: | CLEMSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296331844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644820064 | ||||||||
| FaxNumber: | 8644820081 | ||||||||
| Practice Location | |||||||||
| Address1: | 1715 COUNTRY CLUB RD. | ||||||||
| Address2: | SUITE EFG | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285466042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102194566 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 03/30/2011 | ||||||||
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| AuthorizedOfficialLastName: | BAXTER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8644820064 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.