Provider Demographics
NPI:1033771555
Name:SECOND MILE BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:SECOND MILE BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAGINA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-309-3930
Mailing Address - Street 1:280 LEVI JACKSON MILL RD STE A
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40744-8325
Mailing Address - Country:US
Mailing Address - Phone:606-657-5504
Mailing Address - Fax:
Practice Address - Street 1:280 LEVI JACKSON MILL RD STE A
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40744-8325
Practice Address - Country:US
Practice Address - Phone:606-657-5504
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-04
Last Update Date:2019-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health