1780098228 NPI number — 2ND CHANCE TREATMENT CENTERS LLC

Table of content: (NPI 1780098228)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780098228 NPI number — 2ND CHANCE TREATMENT CENTERS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
2ND CHANCE TREATMENT CENTERS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780098228
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16620 N 40TH ST STE E1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85032-3357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-464-5762
Provider Business Mailing Address Fax Number:
480-428-0475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16620 N 40TH ST STE E-1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85032-3348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-464-9576
Provider Business Practice Location Address Fax Number:
602-626-8901
Provider Enumeration Date:
06/12/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DALE
Authorized Official First Name:
BRANDON
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
602-464-9576

Provider Taxonomy Codes

  • Taxonomy code: 2084P0802X , with the licence number:  48835 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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