Basic Information
Provider Information | |||||||||
NPI: | 1689844557 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CLEMSON SPORTS MEDICINE AND REHABILITATION, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SPORTS PLUS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1844 | ||||||||
Address2: |   | ||||||||
City: | CLEMSON | ||||||||
State: | SC | ||||||||
PostalCode: | 296331844 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8644820064 | ||||||||
FaxNumber: | 8644820081 | ||||||||
Practice Location | |||||||||
Address1: | 800 COLUMBIANA DR | ||||||||
Address2: | SUITE 50 | ||||||||
City: | IRMO | ||||||||
State: | SC | ||||||||
PostalCode: | 290637213 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037329294 | ||||||||
FaxNumber: | 8037329295 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/07/2008 | ||||||||
LastUpdateDate: | 12/20/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BAXTER | ||||||||
AuthorizedOfficialFirstName: | DEBBIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
AuthorizedOfficialTelephone: | 8644820064 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CLEMSON SPORTS MEDICINE AND REHABILITATION, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.