Healthcare Provider Details

I. General information

NPI: 1053139790
Provider Name (Legal Business Name): 2ND CHANCE 2 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 10/01/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2704 BON AIR AVE
WINSTON SALEM NC
27105-4307
US

IV. Provider business mailing address

1856 OLD HOLLOW RD
WALKERTOWN NC
27051-9716
US

V. Phone/Fax

Practice location:
  • Phone: 336-972-4487
  • Fax:
Mailing address:
  • Phone: 336-767-6535
  • 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 Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JULIAN BELTON
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 336-575-7582