MEDICARE: A 2ND CHANCE RECOVERY CENTER, 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	:	1760615041
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A 2ND CHANCE RECOVERY CENTER, 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	:	5607 RINGGOLD RD
Second Line	:
City	:	EAST RIDGE
State	:	TN
Zip	:	37412-3131
Country	:	US
Telephone Number	:	866-374-4673
Fax Number	:	615-453-2609

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

Provider Enumeration Date	:	09/02/2009
Last Update Date	:	09/02/2009

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