MEDICARE: NEW OUTLOOK.. SECOND CHANCE, 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	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568691921
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW OUTLOOK.. SECOND CHANCE, INC.

Provider Business Mailing Address
First Line	:	331 W MAIN ST
Second Line	:	SUITE 302-306
City	:	DURHAM
State	:	NC
Zip	:	27701-3232
Country	:	US
Telephone Number	:	919-682-4771
Fax Number	:

Provider Business Practice Location Address
First Line	:	4801 E INDEPENDENCE BLVD
Second Line	:	SUITE 501
City	:	CHARLOTTE
State	:	NC
Zip	:	28212-5400
Country	:	US
Telephone Number	:	980-226-5528
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MS. BETHENA M JACKSON
Credential	:	BA
Telephone Number	:	919-682-4771

Provider Enumeration Date	:	07/07/2009
Last Update Date	:	07/07/2009

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