Healthcare Provider Details

I. General information

NPI: 1881207652
Provider Name (Legal Business Name): EARNEST E KENNEDY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2020
Last Update Date: 08/31/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 AIRPORT DR
MONCKS CORNER SC
29461-2629
US

IV. Provider business mailing address

96 WISTERIA RD
GOOSE CREEK SC
29445-3495
US

V. Phone/Fax

Practice location:
  • Phone: 843-719-3000
  • Fax:
Mailing address:
  • Phone: 843-797-7871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: JEROME TILGHMAN
Title or Position: DIRECTOR
Credential: LPC, LAC, SAC
Phone: 843-719-3001