Provider Demographics
NPI:1568691921
Name:NEW OUTLOOK.. SECOND CHANCE, INC.
Entity Type:Organization
Organization Name:NEW OUTLOOK.. SECOND CHANCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETHENA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:919-682-4771
Mailing Address - Street 1:331 W MAIN ST
Mailing Address - Street 2:SUITE 302-306
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-3232
Mailing Address - Country:US
Mailing Address - Phone:919-682-4771
Mailing Address - Fax:
Practice Address - Street 1:4801 E INDEPENDENCE BLVD
Practice Address - Street 2:SUITE 501
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-5400
Practice Address - Country:US
Practice Address - Phone:980-226-5528
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW OUTLOOK..SECOND CHANCE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302362BMedicaid
NC8700391Medicaid
NC8302362GMedicaid