Provider Demographics
NPI:1851560072
Name:SECOND CHANCE SLE
Entity Type:Organization
Organization Name:SECOND CHANCE SLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MCCONVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-792-4357
Mailing Address - Street 1:PO BOX 643
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-0643
Mailing Address - Country:US
Mailing Address - Phone:510-792-4357
Mailing Address - Fax:510-745-7693
Practice Address - Street 1:6448 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-4012
Practice Address - Country:US
Practice Address - Phone:510-792-4357
Practice Address - Fax:510-745-1693
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health