Healthcare Provider Details

I. General information

NPI: 1275908352
Provider Name (Legal Business Name): CLEMSON SPORTS MEDICINE AND REHABILITATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2015
Last Update Date: 01/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

838 POWDERSVILLE RD SUITE T
EASLEY SC
29642-3703
US

IV. Provider business mailing address

PO BOX 1844
CLEMSON SC
29633-1844
US

V. Phone/Fax

Practice location:
  • Phone: 864-671-1650
  • Fax: 864-442-2053
Mailing address:
  • Phone: 864-482-0064
  • Fax:

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

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MS. JENNIFER MCQUILLEN
Title or Position: CONTRACTING REP
Credential:
Phone: 864-482-0064