MEDICARE: SECOND CHANCES IN SOUTHERN UTAH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	323P00000X	Psychiatric Residential Treatment Facility	8035	UT
2	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	8035	UT
3	323P00000X	Psychiatric Residential Treatment Facility

General Provider Information

NPI Number	:	1023414182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SECOND CHANCES IN SOUTHERN UTAH, LLC

Provider Business Mailing Address
First Line	:	PO BOX 354
Second Line	:
City	:	LAVERKIN
State	:	UT
Zip	:	84745-8040
Country	:	US
Telephone Number	:	435-669-6669
Fax Number	:	435-571-0374

Provider Business Practice Location Address
First Line	:	591 NORTH STATE
Second Line	:
City	:	LAVERKIN
State	:	UT
Zip	:	84745-8040
Country	:	US
Telephone Number	:	435-669-6669
Fax Number	:	435-571-0374

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR/OWNER
Name	:	ADAM MICHAEL AHQUIN
Credential	:
Telephone Number	:	435-669-6669

Provider Enumeration Date	:	11/17/2014
Last Update Date	:	08/19/2020

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