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General NPI Number Information
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NPI Number | 1730692252
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Entity Type | Organization
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Legal Business Name | 2ND CHANCE AT LIFE, LLC
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Dates
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Enumeration Date | 11/06/2017
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Last Update Date | 11/06/2017
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Provider Practice Location Address
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Address Line | 10425 NW 2ND CT
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City | MIAMI
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State | FL
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Zip | 33150-1128
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Country | US
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Telephone | 786-281-2086
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Fax |
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Provider Business Mailing Address
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Address Line | 5711 NW 21ST ST APT 18B
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City | LAUDERHILL
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State | FL
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Zip | 33313-3108
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Country | US
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Telephone | 239-270-9745
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | NATHALIE R GILLES
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Credential |
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Telephone | 239-270-9745
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State | FL
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