MEDICARE: SECOND CHANCES PEER SUPPORT 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	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1073458220
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SECOND CHANCES PEER SUPPORT LLC

Provider Business Mailing Address
First Line	:	3226 LILAC GROVE DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-0652
Country	:	US
Telephone Number	:	704-299-2825
Fax Number	:	704-299-2825

Provider Business Practice Location Address
First Line	:	3226 LILAC GROVE DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-0652
Country	:	US
Telephone Number	:	704-299-2825
Fax Number	:	704-299-2825

Authorized Official
Title or Position	:	CFO
Name	:	EBONY KEITH
Credential	:	KEITH
Telephone Number	:	704-299-2825

Provider Enumeration Date	:	04/22/2026
Last Update Date	:	04/22/2026

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