1710398045 NPI number — SECOND CHANCE LIVING SUPPORTIVE SERVICES

Table of content: (NPI 1710398045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710398045 NPI number — SECOND CHANCE LIVING SUPPORTIVE SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SECOND CHANCE LIVING SUPPORTIVE 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:
6
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:
1710398045
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
269 WALKER ST
Provider Second Line Business Mailing Address:
SUITE 538
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48207-4258
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-610-0134
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3031 W GRAND BLVD STE 522
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48202-3187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-313-4775
Provider Business Practice Location Address Fax Number:
313-566-9229
Provider Enumeration Date:
05/08/2014

Additional Information

Authorized Official

Authorized Official Last Name:
KILGORE
Authorized Official First Name:
DARREN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DORECTOR
Authorized Official Telephone Number:
248-313-4775

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





Copyright © 2007-2025 www.npivalidator.com