Healthcare Provider Details

I. General information

NPI: 1720160450
Provider Name (Legal Business Name): CLEMSON SPORTS MEDICINE AND REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 11/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4237 RIVER HILLS DR SUITE 120
LITTLE RIVER SC
29566-6444
US

IV. Provider business mailing address

PO BOX 1844
CLEMSON SC
29633-1844
US

V. Phone/Fax

Practice location:
  • Phone: 843-249-5616
  • Fax: 843-249-1843
Mailing address:
  • Phone: 864-482-0064
  • Fax: 864-482-0081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number State
# 4
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