Basic Information
| Provider Information | |||||||||
| NPI: | 1679705628 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPORTS PLUS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 COLUMBIANA DR STE 50 | ||||||||
| Address2: | |||||||||
| City: | IRMO | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290637214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037329294 | ||||||||
| FaxNumber: | 8037329295 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 COLUMBIANA DR STE 50 | ||||||||
| Address2: | |||||||||
| City: | IRMO | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290637214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037329294 | ||||||||
| FaxNumber: | 8037329295 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2009 | ||||||||
| LastUpdateDate: | 08/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | WILMOT | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | A/R SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 8644820064 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLEMSON SPORTS MEDICINE | ||||||||
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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.