MEDICARE: SECOND CHANCE COMMUNITY HEALTH

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	1041C0700X	Clinical Social Worker
2	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1871474536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SECOND CHANCE COMMUNITY HEALTH

Provider Business Mailing Address
First Line	:	732 S 6TH ST STE R
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89101-6948
Country	:	US
Telephone Number	:	702-482-8580
Fax Number	:

Provider Business Practice Location Address
First Line	:	732 S 6TH ST STE R
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89101-6948
Country	:	US
Telephone Number	:	702-482-8580
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CARLOS RUBEN CISNEROS
Credential	:	LCSW
Telephone Number	:	702-482-8580

Provider Enumeration Date	:	09/09/2025
Last Update Date	:	01/14/2026

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