Provider Demographics
NPI:1568128957
Name:2ND CHANCE
Entity Type:Organization
Organization Name:2ND CHANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BISHIOP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-368-8820
Mailing Address - Street 1:1420 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40505-3155
Mailing Address - Country:US
Mailing Address - Phone:859-368-8820
Mailing Address - Fax:
Practice Address - Street 1:1420 N BROADWAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-3155
Practice Address - Country:US
Practice Address - Phone:859-368-8820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:2ND CHANCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty