Provider Demographics
NPI:1023414182
Name:SECOND CHANCES IN SOUTHERN UTAH, LLC
Entity type:Organization
Organization Name:SECOND CHANCES IN SOUTHERN UTAH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:AHQUIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-669-6669
Mailing Address - Street 1:PO BOX 354
Mailing Address - Street 2:
Mailing Address - City:LAVERKIN
Mailing Address - State:UT
Mailing Address - Zip Code:84745-8040
Mailing Address - Country:US
Mailing Address - Phone:435-669-6669
Mailing Address - Fax:435-571-0374
Practice Address - Street 1:591 NORTH STATE
Practice Address - Street 2:
Practice Address - City:LAVERKIN
Practice Address - State:UT
Practice Address - Zip Code:84745-8040
Practice Address - Country:US
Practice Address - Phone:435-669-6669
Practice Address - Fax:435-571-0374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-17
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8035323P00000X, 322D00000X, 323P00000X, 324500000X
323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children