Basic Information
| Provider Information | |||||||||
| NPI: | 1689010308 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLEMSON SPORTS MEDICINE AND REHABILITATION, INC | ||||||||
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| OtherOrganizationName: | GOOSE CREEK PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1844 | ||||||||
| Address2: | |||||||||
| City: | CLEMSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296331844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644820064 | ||||||||
| FaxNumber: | 8644820081 | ||||||||
| Practice Location | |||||||||
| Address1: | 217A SAINT JAMES AVE | ||||||||
| Address2: | |||||||||
| City: | GOOSE CREEK | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294452990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435315495 | ||||||||
| FaxNumber: | 8432776232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2013 | ||||||||
| LastUpdateDate: | 03/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | MCQUILLEN | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8644820064 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CLEMSON SPORTS MEDICINE AND REHABILITATION, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 273Y00000X | Y | Hospital Units | Rehabilitation Unit |
No ID Information.