Provider Demographics
NPI:1275908352
Name:CLEMSON SPORTS MEDICINE AND REHABILITATION INC
Entity Type:Organization
Organization Name:CLEMSON SPORTS MEDICINE AND REHABILITATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING REP
Authorized Official - Prefix:MS
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: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:
Practice Address - Street 1:838 POWDERSVILLE RD
Practice Address - Street 2:SUITE T
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29642-3703
Practice Address - Country:US
Practice Address - Phone:864-671-1650
Practice Address - Fax:864-442-2053
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEMSON SPORTS MEDICINE AND REHABILITATION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-01
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy