Provider Demographics
NPI:1922487610
Name:CORNERSTONE PROJECT SC, LLC
Entity Type:Organization
Organization Name:CORNERSTONE PROJECT SC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, NCACII
Authorized Official - Phone:803-210-9554
Mailing Address - Street 1:1919 HAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3535
Mailing Address - Country:US
Mailing Address - Phone:803-764-3798
Mailing Address - Fax:
Practice Address - Street 1:1919 HAMPTON ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3535
Practice Address - Country:US
Practice Address - Phone:803-764-3798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261QR405X261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder