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General NPI Number Information
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NPI Number | 1740439603
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Entity Type | Organization
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Legal Business Name | SECOND GENESIS
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Dates
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Enumeration Date | 09/16/2008
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Last Update Date | 09/16/2008
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Provider Practice Location Address
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Address Line | 4017 MINNESOTA AVE NE
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City | WASHINGTON
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State | DC
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Zip | 20019-3541
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Country | US
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Telephone | 202-388-8570
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Fax | 202-388-3523
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Provider Business Mailing Address
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Address Line | 8611 2ND AVE SUITE 300
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City | SILVER SPRING
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State | MD
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Zip | 20910-3372
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Country | US
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Telephone | 301-563-1545
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Fax | 301-563-1546
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. J. MICHAEL MCGUINNESS
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Credential | M.S.W.
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Telephone | 301-563-1545
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 111507A-171
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License Number State | DC
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Taxonomy #2
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 111507A-Y-170
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License Number State | DC
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