=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346897295
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 2NDCHANCEHAVEN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2019
-----------------------------------------------------
Last Update Date | 09/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 ELIZABETH PL
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45417-3445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-912-2674
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2339 HARRODSBURG RD
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40504-3327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICDC
-----------------------------------------------------
Name | RODNEY HUNTER
-----------------------------------------------------
Credential | LICDC
-----------------------------------------------------
Telephone | 502-912-2674
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------