Provider Demographics
NPI:1245795269
Name:SECOND CHANCE SUPPORT SERVICES LLC
Entity Type:Organization
Organization Name:SECOND CHANCE SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ROBINSON
Authorized Official - Last Name:EANES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-203-7538
Mailing Address - Street 1:22 E CHURCH ST STE 318
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-6208
Mailing Address - Country:US
Mailing Address - Phone:276-403-5084
Mailing Address - Fax:276-403-4207
Practice Address - Street 1:22 E CHURCH ST STE 319
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-6208
Practice Address - Country:US
Practice Address - Phone:276-403-5084
Practice Address - Fax:276-403-4207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAS5590577OtherSTATE CORPORATION COMMISSION