Provider Demographics
NPI:1093041766
Name:SECOND CHANCE RANCH
Entity Type:Organization
Organization Name:SECOND CHANCE RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE MANAGER/TEACHER
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WINIECKI
Authorized Official - Suffix:
Authorized Official - Credentials:MHPP
Authorized Official - Phone:501-847-1559
Mailing Address - Street 1:PO BOX 901
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72089-0901
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 DESTINED TO WIN ROAD
Practice Address - Street 2:
Practice Address - City:PARON
Practice Address - State:AR
Practice Address - Zip Code:72122
Practice Address - Country:US
Practice Address - Phone:501-847-1559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-30
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service