MEDICARE: SECOND CHANCE LIVING INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1538321567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SECOND CHANCE LIVING INC

Provider Business Mailing Address
First Line	:	3011 S MEMORIAL DR
Second Line	:	SUITE #11
City	:	GREENVILLE
State	:	NC
Zip	:	27834-6238
Country	:	US
Telephone Number	:	252-814-1899
Fax Number	:

Provider Business Practice Location Address
First Line	:	3011 S MEMORIAL DR
Second Line	:	SUITE #11
City	:	GREENVILLE
State	:	NC
Zip	:	27834-6238
Country	:	US
Telephone Number	:	252-814-1899
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	BAKARRI K JOHNSON
Credential	:	B,A.
Telephone Number	:	252-814-1899

Provider Enumeration Date	:	07/01/2008
Last Update Date	:	08/18/2009

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Directions to “SECOND CHANCE LIVING INC ” Practice Location

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