MEDICARE: 2ND CHANCES FAMILY SERVICES

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1629728423
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	2ND CHANCES FAMILY SERVICES

Provider Business Mailing Address
First Line	:	1430 STRICKLAND ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75216-1314
Country	:	US
Telephone Number	:	214-288-9508
Fax Number	:

Provider Business Practice Location Address
First Line	:	1430 STRICKLAND ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75216-1314
Country	:	US
Telephone Number	:	214-288-9508
Fax Number	:

Authorized Official
Title or Position	:	PROPRIETOR
Name	:	JEREMIAH GRIMES
Credential	:
Telephone Number	:	214-288-9508

Provider Enumeration Date	:	03/24/2022
Last Update Date	:	03/24/2022

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