Provider Demographics
NPI:1104069905
Name:NEW OUTLOOK SECOND CHANCE, INC.
Entity type:Organization
Organization Name:NEW OUTLOOK SECOND CHANCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BETHENA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-682-4771
Mailing Address - Street 1:331 W MAIN ST
Mailing Address - Street 2:SUITE 302-306
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-3232
Mailing Address - Country:US
Mailing Address - Phone:919-682-4771
Mailing Address - Fax:919-683-2641
Practice Address - Street 1:331 W MAIN ST
Practice Address - Street 2:SUITE 302-306
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-3232
Practice Address - Country:US
Practice Address - Phone:919-682-4771
Practice Address - Fax:919-683-2641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302362BMedicaid
NC8302362GMedicaid