Healthcare Provider Details

I. General information

NPI: 1073458220
Provider Name (Legal Business Name): SECOND CHANCES PEER SUPPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3226 LILAC GROVE DR
CHARLOTTE NC
28269-0652
US

IV. Provider business mailing address

3226 LILAC GROVE DR
CHARLOTTE NC
28269-0652
US

V. Phone/Fax

Practice location:
  • Phone: 704-299-2825
  • Fax: 704-299-2825
Mailing address:
  • Phone: 704-299-2825
  • Fax: 704-299-2825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name: EBONY KEITH
Title or Position: CFO
Credential: KEITH
Phone: 704-299-2825