Provider Demographics
NPI:1104995182
Name:SECOND CHANCE FOR YOU
Entity type:Organization
Organization Name:SECOND CHANCE FOR YOU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KERTRENIA
Authorized Official - Middle Name:SHANICKA
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:704-807-5910
Mailing Address - Street 1:1526 PEACHCROFT RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216
Mailing Address - Country:US
Mailing Address - Phone:704-399-4464
Mailing Address - Fax:
Practice Address - Street 1:2213 SOUTHWIND DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-8846
Practice Address - Country:US
Practice Address - Phone:704-399-6320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC060-1002320600000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Not Answered320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities