Healthcare Provider Details

I. General information

NPI: 1275530503
Provider Name (Legal Business Name): CLEMSON SPORTS MEDICINE AND REHABILITATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 11/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10626 CLEMSON BLVD
SENECA SC
29678-4526
US

IV. Provider business mailing address

PO BOX 1844
CLEMSON SC
29633-1844
US

V. Phone/Fax

Practice location:
  • Phone: 864-482-0064
  • Fax: 864-482-0074
Mailing address:
  • Phone: 864-482-0064
  • Fax: 864-482-0074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

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