Provider Demographics
NPI:1174903009
Name:LIONS DEN RECREATION CENTER, THE
Entity type:Organization
Organization Name:LIONS DEN RECREATION CENTER, THE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REHABILITATION SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:H. CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:COTA/L
Authorized Official - Phone:843-819-9470
Mailing Address - Street 1:4159 DORCHESTER RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405
Mailing Address - Country:US
Mailing Address - Phone:843-718-3064
Mailing Address - Fax:843-718-3064
Practice Address - Street 1:4159 DORCHESTER RD
Practice Address - Street 2:SUITE B
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-7426
Practice Address - Country:US
Practice Address - Phone:843-718-3064
Practice Address - Fax:843-718-3064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC981173000000X, 251V00000X, 276400000X, 291U00000X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
No251V00000XAgenciesVoluntary or Charitable
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
No291U00000XLaboratoriesClinical Medical Laboratory