Provider Demographics
NPI:1780133363
Name:SECOND CHANCE
Entity type:Organization
Organization Name:SECOND CHANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAHOGANY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-809-0993
Mailing Address - Street 1:1428 DESERT RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-5003
Mailing Address - Country:US
Mailing Address - Phone:702-809-0993
Mailing Address - Fax:
Practice Address - Street 1:1428 DESERT RIDGE AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-5003
Practice Address - Country:US
Practice Address - Phone:702-809-0993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-24
Last Update Date:2016-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20161565425251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health