Healthcare Provider Details

I. General information

NPI: 1285837583
Provider Name (Legal Business Name): SECOND CHANCE CABRILLO CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4673 THORNTON AVENUE SUITE P
FREEMONT CA
94536
US

IV. Provider business mailing address

BOX 643
NEWARK CA
94560
US

V. Phone/Fax

Practice location:
  • Phone: 510-745-1675
  • Fax: 510-744-0674
Mailing address:
  • Phone: 510-792-4357
  • Fax: 510-745-1692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0193
License Number StateCA

VIII. Authorized Official

Name: MARK R MCCONVILLE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 510-792-4357