=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205165495
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANOTHER CHANCE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2009
-----------------------------------------------------
Last Update Date | 12/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 BATTLEGROUND AVE STE. 150-F
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27408-8042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-669-6283
-----------------------------------------------------
Fax | 336-698-3849
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 BATTLEGROUND AVE STE. 150-F
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27408-8042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-669-6283
-----------------------------------------------------
Fax | 336-698-3849
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DIRECTOR
-----------------------------------------------------
Name | MS. BONNIE RENEE CASKEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-669-6283
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 221265
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 221265
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------