Healthcare Provider Details

I. General information

NPI: 1881701688
Provider Name (Legal Business Name): CLEMSON SPORTS MEDICINE AND REHABILITATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 11/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

936 COX RD
GASTONIA NC
28054-3456
US

IV. Provider business mailing address

PO BOX 1844
CLEMSON SC
29633-1844
US

V. Phone/Fax

Practice location:
  • Phone: 704-823-1525
  • Fax: 704-823-9850
Mailing address:
  • Phone: 864-482-0064
  • Fax: 864-482-0081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: CHARLEEN FITZGERALD
Title or Position: CREDENTIALING
Credential:
Phone: 864-482-0064