MEDICARE: ANOTHER CHANCE AT LIFE INC.

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1497031140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANOTHER CHANCE AT LIFE INC.

Provider Business Mailing Address
First Line	:	424 VANCE LN
Second Line	:
City	:	LEBANON
State	:	TN
Zip	:	37087-0368
Country	:	US
Telephone Number	:	866-374-4673
Fax Number	:	615-453-2609

Provider Business Practice Location Address
First Line	:	4220 DAYTON BLVD
Second Line	:	SUITE F
City	:	RED BANK
State	:	TN
Zip	:	37415-2790
Country	:	US
Telephone Number	:	866-388-9514
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. BILLY J BOOTH
Credential	:
Telephone Number	:	615-804-3551

Provider Enumeration Date	:	10/26/2011
Last Update Date	:	11/18/2013

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