Provider Demographics
NPI:1851614762
Name:HOME OF SECOND CHANCES, LLC
Entity Type:Organization
Organization Name:HOME OF SECOND CHANCES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:K
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-285-9031
Mailing Address - Street 1:2216 W MEADOWVIEW RD STE 105
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-3401
Mailing Address - Country:US
Mailing Address - Phone:336-285-9031
Mailing Address - Fax:336-285-9032
Practice Address - Street 1:2216 W MEADOWVIEW RD STE 105
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-3401
Practice Address - Country:US
Practice Address - Phone:336-285-9031
Practice Address - Fax:336-285-9032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302865HMedicaid
NC8302865BMedicaid