=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144457813
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOME OF SECOND CHANCES,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2009
-----------------------------------------------------
Last Update Date | 06/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2308 MICHELLE LN
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27407-4923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-987-3460
-----------------------------------------------------
Fax | 336-375-0623
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2308 MICHELLE LN
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27407-4923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-987-3460
-----------------------------------------------------
Fax | 336-375-0623
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. CYNTHIA JONES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-987-0623
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | MHL041915
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------