Provider Demographics
NPI:1851527261
Name:CLEMSON SPORTS MEDICINE AND REHABILITATION, INC.
Entity Type:Organization
Organization Name:CLEMSON SPORTS MEDICINE AND REHABILITATION, INC.
Other - Org Name:MYRTLE BEACH PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
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 1:210 VILLAGE CENTER BLVD
Practice Address - Street 2:STE 100
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-6706
Practice Address - Country:US
Practice Address - Phone:843-491-4937
Practice Address - Fax:843-491-4938
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLEMSON SPORTS MEDICINE AND REHABILITATION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-01
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5092260007Medicare NSC