MEDICARE: SECOND CHANCE SUPPORT SERVICES 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	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	S5590577	OTHER	VA	STATE CORPORATION COMMISSION

General Provider Information

NPI Number	:	1245795269
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SECOND CHANCE SUPPORT SERVICES LLC

Provider Business Mailing Address
First Line	:	22 E CHURCH ST STE 318
Second Line	:
City	:	MARTINSVILLE
State	:	VA
Zip	:	24112-6208
Country	:	US
Telephone Number	:	276-403-5084
Fax Number	:	276-403-4207

Provider Business Practice Location Address
First Line	:	22 E CHURCH ST STE 319
Second Line	:
City	:	MARTINSVILLE
State	:	VA
Zip	:	24112-6208
Country	:	US
Telephone Number	:	276-403-5084
Fax Number	:	276-403-4207

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. KELLY ROBINSON EANES
Credential	:
Telephone Number	:	434-203-7538

Provider Enumeration Date	:	02/04/2019
Last Update Date	:	02/04/2019

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