Healthcare Provider Details

I. General information

NPI: 1164987376
Provider Name (Legal Business Name): SECOND CHANCE RECOVERY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2019
Last Update Date: 02/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 E ROUTE 66 STE 209
GLENDORA CA
91740-3778
US

IV. Provider business mailing address

1135 E ROUTE 66 STE 209
GLENDORA CA
91740-3778
US

V. Phone/Fax

Practice location:
  • Phone: 626-353-4289
  • Fax:
Mailing address:
  • Phone: 626-353-4289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMY ROBERTS
Title or Position: CEO/OWNER
Credential:
Phone: 626-353-4289