Healthcare Provider Details

I. General information

NPI: 1942432455
Provider Name (Legal Business Name): SPORTS PLUS
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

306 STATION 22 1/2 ST
SULLIVANS ISLAND SC
29482-9756
US

IV. Provider business mailing address

PO BOX 1844
CLEMSON SC
29633-1844
US

V. Phone/Fax

Practice location:
  • Phone: 843-883-0054
  • Fax: 843-883-0064
Mailing address:
  • Phone: 864-448-2006
  • 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