Provider Demographics
NPI:1285837583
Name:SECOND CHANCE CABRILLO CENTER
Entity Type:Organization
Organization Name:SECOND CHANCE CABRILLO CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCCONVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-792-4357
Mailing Address - Street 1:BOX 643
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560
Mailing Address - Country:US
Mailing Address - Phone:510-792-4357
Mailing Address - Fax:510-745-1692
Practice Address - Street 1:4673 THORNTON AVENUE
Practice Address - Street 2:SUITE P
Practice Address - City:FREEMONT
Practice Address - State:CA
Practice Address - Zip Code:94536
Practice Address - Country:US
Practice Address - Phone:510-745-1675
Practice Address - Fax:510-744-0674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0193251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health