1891935045 NPI number — SECOND CHANCES OUTPATIENT SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891935045 NPI number — SECOND CHANCES OUTPATIENT SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SECOND CHANCES OUTPATIENT SERVICES
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:
1891935045
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 E STANLEY ST
Provider Second Line Business Mailing Address:
103
Provider Business Mailing Address City Name:
CROSSVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38555-3200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-267-4809
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 E STANLEY ST
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
CROSSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38555-3200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-267-4809
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/01/2009

Additional Information

Authorized Official

Authorized Official Last Name:
COX
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
PROGRAM DIRECTOR
Authorized Official Telephone Number:
931-267-4809

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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