Healthcare Provider Details

I. General information

NPI: 1396977955
Provider Name (Legal Business Name): CLEMSON SPORTS MEDICINE AND REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2009
Last Update Date: 08/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12023 N RADIO STATION RD STE A
SENECA SC
29678-1143
US

IV. Provider business mailing address

PO BOX 1844
CLEMSON SC
29633-1844
US

V. Phone/Fax

Practice location:
  • Phone: 864-985-0770
  • Fax: 864-985-1770
Mailing address:
  • Phone: 864-482-0064
  • Fax: 864-482-0081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER WILMOT
Title or Position: A/R SUPERVISOR
Credential:
Phone: 864-482-0064