Provider Demographics
NPI:1386886588
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:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAXTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-482-0064
Mailing Address - Street 1:PO BOX 1844
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29633-1844
Mailing Address - Country:US
Mailing Address - Phone:864-482-0064
Mailing Address - Fax:864-482-0074
Practice Address - Street 1:4237 RIVER HILLS DR
Practice Address - Street 2:SUITE 120
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-6444
Practice Address - Country:US
Practice Address - Phone:843-249-5616
Practice Address - Fax:843-249-1843
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEMSON SPORTS MEDICINE AND REHABILITATION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-02
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5092260004Medicare NSC