Provider Demographics
NPI:1679658785
Name:CLEMSON SPORTS MEDICINE AND REHABILITATION
Entity Type:Organization
Organization Name:CLEMSON SPORTS MEDICINE AND REHABILITATION
Other - Org Name:THE BALANCE, MOBILITY AND DIZZINESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER/PT
Authorized Official - Prefix:
Authorized Official - First Name:STUART
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNTER
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 1:3185 AZALEA DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-8211
Practice Address - Country:US
Practice Address - Phone:843-225-2240
Practice Address - Fax:843-225-2241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC426584Medicare ID - Type Unspecified