Basic Information
| Provider Information | |||||||||
| NPI: | 1205062619 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLEMSON SPORTS MEDICINE AND REHABILITATION, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | SPORTS PLUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1844 | ||||||||
| Address2: | |||||||||
| City: | CLEMSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296331844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644820064 | ||||||||
| FaxNumber: | 8644820074 | ||||||||
| Practice Location | |||||||||
| Address1: | 2881 TRICOM ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | N CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437977095 | ||||||||
| FaxNumber: | 8437977097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2009 | ||||||||
| LastUpdateDate: | 04/25/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAXTER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8644820064 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLEMSON SPORTS MEDICINE & REHABILITATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.