Healthcare Provider Details

I. General information

NPI: 1689430498
Provider Name (Legal Business Name): ANOTHER CHANCE IHS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2024
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 MILL ST
CHILLICOTHEE OH
45601-2322
US

IV. Provider business mailing address

536 MILL ST
CHILLICOTHEE OH
45601-2322
US

V. Phone/Fax

Practice location:
  • Phone: 740-330-4988
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSIE COSTLEY
Title or Position: DIRECTOR OF PROVIDER ENROLLMENT
Credential:
Phone: 443-839-6928