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General NPI Number Information
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NPI Number | 1073458220
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Entity Type | Organization
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Legal Business Name | SECOND CHANCES PEER SUPPORT LLC
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Dates
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Enumeration Date | 04/22/2026
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Last Update Date | 04/22/2026
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Provider Practice Location Address
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Address Line | 3226 LILAC GROVE DR
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City | CHARLOTTE
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State | NC
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Zip | 28269-0652
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Country | US
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Telephone | 704-299-2825
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Fax | 704-299-2825
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Provider Business Mailing Address
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Address Line | 3226 LILAC GROVE DR
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City | CHARLOTTE
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State | NC
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Zip | 28269-0652
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Country | US
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Telephone | 704-299-2825
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Fax | 704-299-2825
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Authorized Official
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Title or Position | CFO
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Name | EBONY KEITH
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Credential | KEITH
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Telephone | 704-299-2825
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State |
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