Provider Demographics
NPI:1083808497
Name:SECOND CHANCE FOR YOU
Entity Type:Organization
Organization Name:SECOND CHANCE FOR YOU
Other - Org Name:SECOND CHANCE 4 KIDZ
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KERTRENIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-807-5910
Mailing Address - Street 1:2213 SOUTHWIND DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-8846
Mailing Address - Country:US
Mailing Address - Phone:704-231-2889
Mailing Address - Fax:704-971-0131
Practice Address - Street 1:1526 PEACHCROFT RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-2747
Practice Address - Country:US
Practice Address - Phone:704-231-2889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0601002320600000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805669Medicaid