Healthcare Provider Details

I. General information

NPI: 1174903009
Provider Name (Legal Business Name): LIONS DEN RECREATION CENTER, THE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 06/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4159 DORCHESTER RD SUITE B
NORTH CHARLESTON SC
29405-7426
US

IV. Provider business mailing address

4159 DORCHESTER RD SUITE B
NORTH CHARLESTON SC
29405
US

V. Phone/Fax

Practice location:
  • Phone: 843-718-3064
  • Fax: 843-718-3064
Mailing address:
  • Phone: 843-718-3064
  • Fax: 843-718-3064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number981
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number981
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number981
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number981
License Number StateSC
# 5
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number981
License Number StateSC

VIII. Authorized Official

Name: H. CRAIG JACKSON
Title or Position: DIRECTOR OF REHABILITATION SERVICES
Credential: COTA/L
Phone: 843-819-9470