Provider Demographics
NPI:1154727907
Name:CLEMSON SPORTS MEDICINE AND REHABILITATION
Entity type:Organization
Organization Name:CLEMSON SPORTS MEDICINE AND REHABILITATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MCQUILLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-482-0064
Mailing Address - Street 1:1909 N HIGHWAY 17
Mailing Address - Street 2:SUITE Q
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7459
Mailing Address - Country:US
Mailing Address - Phone:843-416-9026
Mailing Address - Fax:843-531-6223
Practice Address - Street 1:1909 N HIGHWAY 17
Practice Address - Street 2:SUITE Q
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7459
Practice Address - Country:US
Practice Address - Phone:843-416-9026
Practice Address - Fax:843-531-6223
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEMSON SPORTS MEDICINE AND REHABILITATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes273Y00000XHospital UnitsRehabilitation Unit
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC426584Medicare Oscar/Certification