MEDICARE: SECOND CHANCE RANCH

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	305S00000X	Point of Service		AR

General Provider Information

NPI Number	:	1861725590
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SECOND CHANCE RANCH

Provider Business Mailing Address
First Line	:	PO BOX 901
Second Line	:
City	:	BRYANT
State	:	AR
Zip	:	72089
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 DESTINED TO WIN ROAD
Second Line	:
City	:	PARON
State	:	AR
Zip	:	72122
Country	:	US
Telephone Number	:	501-847-1559
Fax Number	:

Authorized Official
Title or Position	:	CASE MANAGER
Name	:	MRS. LAINNA JEAN HENLEY
Credential	:	MHPP
Telephone Number	:	501-847-1559

Provider Enumeration Date	:	09/14/2009
Last Update Date	:	07/21/2022

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Directions to “SECOND CHANCE RANCH ” Practice Location

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