Healthcare Provider Details

I. General information

NPI: 1710461132
Provider Name (Legal Business Name): WADE HAMPTON SHUGART IV PT, DPT, OCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 09/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 FIKE REC CENTER
CLEMSON SC
29634-0001
US

IV. Provider business mailing address

205 FIKE REC CENTER
CLEMSON SC
29634-0001
US

V. Phone/Fax

Practice location:
  • Phone: 864-643-1344
  • Fax:
Mailing address:
  • Phone: 864-643-1344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT.9352
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: