MEDICARE: SECOND CHANCE HOME 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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1639884620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SECOND CHANCE HOME LLC

Provider Business Mailing Address
First Line	:	2805 94TH WAY
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55444-2958
Country	:	US
Telephone Number	:	952-454-3206
Fax Number	:

Provider Business Practice Location Address
First Line	:	2805 94TH WAY
Second Line	:
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55444-2958
Country	:	US
Telephone Number	:	952-454-1157
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MOHAMED YUSUF DAWID
Credential	:
Telephone Number	:	952-454-1157

Provider Enumeration Date	:	01/16/2023
Last Update Date	:	01/16/2023

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