Healthcare Provider Details

I. General information

NPI: 1710398045
Provider Name (Legal Business Name): SECOND CHANCE LIVING SUPPORTIVE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2014
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 W GRAND BLVD STE 522
DETROIT MI
48202-3187
US

IV. Provider business mailing address

269 WALKER ST SUITE 538
DETROIT MI
48207-4258
US

V. Phone/Fax

Practice location:
  • Phone: 248-313-4775
  • Fax: 313-566-9229
Mailing address:
  • Phone: 313-610-0134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: DARREN KILGORE
Title or Position: EXECUTIVE DORECTOR
Credential:
Phone: 248-313-4775