Provider Demographics
NPI:1639884620
Name:SECOND CHANCE HOME LLC
Entity Type:Organization
Organization Name:SECOND CHANCE HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:YUSUF
Authorized Official - Last Name:DAWID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-454-1157
Mailing Address - Street 1:2805 94TH WAY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55444-2958
Mailing Address - Country:US
Mailing Address - Phone:952-454-3206
Mailing Address - Fax:
Practice Address - Street 1:2805 94TH WAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55444-2958
Practice Address - Country:US
Practice Address - Phone:952-454-1157
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management