Healthcare Provider Details

I. General information

NPI: 1851560072
Provider Name (Legal Business Name): SECOND CHANCE SLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2008
Last Update Date: 02/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6448 BROADWAY AVE
NEWARK CA
94560-4012
US

IV. Provider business mailing address

PO BOX 643
NEWARK CA
94560-0643
US

V. Phone/Fax

Practice location:
  • Phone: 510-792-4357
  • Fax: 510-745-1693
Mailing address:
  • Phone: 510-792-4357
  • Fax: 510-745-7693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MARK ROBERT MCCONVILLE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 510-792-4357