Healthcare Provider Details

I. General information

NPI: 1154727907
Provider Name (Legal Business Name): CLEMSON SPORTS MEDICINE AND REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2014
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 N HIGHWAY 17 SUITE Q
MT PLEASANT SC
29464-7459
US

IV. Provider business mailing address

1909 N HIGHWAY 17 SUITE Q
MT PLEASANT SC
29464-7459
US

V. Phone/Fax

Practice location:
  • Phone: 843-416-9026
  • Fax: 843-531-6223
Mailing address:
  • Phone: 843-416-9026
  • Fax: 843-531-6223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER MCQUILLEN
Title or Position: BILLING
Credential:
Phone: 864-482-0064