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General NPI Number Information
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NPI Number | 1285837583
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Entity Type | Organization
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Legal Business Name | SECOND CHANCE CABRILLO CENTER
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Dates
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Enumeration Date | 06/06/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4673 THORNTON AVENUE SUITE P
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City | FREEMONT
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State | CA
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Zip | 94536
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Country | US
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Telephone | 510-745-1675
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Fax | 510-744-0674
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Provider Business Mailing Address
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Address Line | BOX 643
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City | NEWARK
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State | CA
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Zip | 94560
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Country | US
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Telephone | 510-792-4357
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Fax | 510-745-1692
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MARK R MCCONVILLE
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Credential |
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Telephone | 510-792-4357
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 0193
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License Number State | CA
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