MEDICARE: CLEMSON SPORTS MEDICINE AND REHABILITATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center		SC
2	273Y00000X	Rehabilitation Hospital Unit

General Provider Information

NPI Number	:	1881850634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEMSON SPORTS MEDICINE AND REHABILITATION

Provider Business Mailing Address
First Line	:	PO BOX 1844
Second Line	:
City	:	CLEMSON
State	:	SC
Zip	:	29633-1844
Country	:	US
Telephone Number	:	864-482-0064
Fax Number	:	864-482-0081

Provider Business Practice Location Address
First Line	:	1051 STAMP CREEK RD
Second Line	:
City	:	SALEM
State	:	SC
Zip	:	29676-4516
Country	:	US
Telephone Number	:	864-944-5146
Fax Number	:	864-944-5147

Authorized Official
Title or Position	:	OWNER
Name	:	STUART HUNTER
Credential	:
Telephone Number	:	864-482-0064

Provider Enumeration Date	:	07/31/2008
Last Update Date	:	11/17/2014

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