Healthcare Provider Details

I. General information

NPI: 1861725590
Provider Name (Legal Business Name): SECOND CHANCE RANCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 DESTINED TO WIN ROAD
PARON AR
72122
US

IV. Provider business mailing address

PO BOX 901
BRYANT AR
72089
US

V. Phone/Fax

Practice location:
  • Phone: 501-847-1559
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number StateAR

VIII. Authorized Official

Name: MRS. LAINNA JEAN HENLEY
Title or Position: CASE MANAGER
Credential: MHPP
Phone: 501-847-1559