Provider Demographics
NPI:1326006222
Name:CLEMSON SPORTS MEDICINE AND REHABILITATION, INC
Entity Type:Organization
Organization Name:CLEMSON SPORTS MEDICINE AND REHABILITATION, INC
Other - Org Name:SPORTS PLUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:CHARLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FITZGERALD
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:864-482-0081
Practice Address - Street 1:1140 WARM SPRINGS HWY
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:GA
Practice Address - Zip Code:31816-1166
Practice Address - Country:US
Practice Address - Phone:706-846-3717
Practice Address - Fax:706-846-3721
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEMSON SPORTS MEDICINE AND REHABILITATION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-02
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA222261QP2000X
273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
116866Medicare Oscar/Certification