Provider Demographics
NPI:1710398045
Name:SECOND CHANCE LIVING SUPPORTIVE SERVICES
Entity Type:Organization
Organization Name:SECOND CHANCE LIVING SUPPORTIVE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-610-0134
Mailing Address - Street 1:269 WALKER ST
Mailing Address - Street 2:SUITE 538
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4258
Mailing Address - Country:US
Mailing Address - Phone:313-610-0134
Mailing Address - Fax:
Practice Address - Street 1:2040 CHENE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-3832
Practice Address - Country:US
Practice Address - Phone:313-610-0134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-08
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care