Provider Demographics
NPI:1689010308
Name:CLEMSON SPORTS MEDICINE AND REHABILITATION, INC
Entity Type:Organization
Organization Name:CLEMSON SPORTS MEDICINE AND REHABILITATION, INC
Other - Org Name:GOOSE CREEK PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
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: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 1:217A SAINT JAMES AVE
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-2990
Practice Address - Country:US
Practice Address - Phone:843-531-5495
Practice Address - Fax:843-277-6232
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEMSON SPORTS MEDICINE AND REHABILITATION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-21
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC426584Medicare Oscar/Certification