Healthcare Provider Details

I. General information

NPI: 1578808432
Provider Name (Legal Business Name): ANOTHER CHANCE YOUTH MINISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2012
Last Update Date: 03/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 S BECKLEY AVE
DALLAS TX
75224-2004
US

IV. Provider business mailing address

1622 S BECKLEY AVE
DALLAS TX
75224-2004
US

V. Phone/Fax

Practice location:
  • Phone: 469-324-6253
  • Fax: 469-206-6611
Mailing address:
  • Phone: 469-324-6253
  • Fax: 469-206-6611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number15089177
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number15089177CDL
License Number StateTX

VIII. Authorized Official

Name: MS. LUELLA CHILDS
Title or Position: PASTOR / CEO-FOUNDER
Credential: PASTOR
Phone: 469-324-6253