Provider Demographics
NPI:1114309333
Name:SECOND CHANCE OF NORTHWEST FLORIDA
Entity type:Organization
Organization Name:SECOND CHANCE OF NORTHWEST FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:CUPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-769-7779
Mailing Address - Street 1:819 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-3459
Mailing Address - Country:US
Mailing Address - Phone:850-769-7779
Mailing Address - Fax:850-215-7718
Practice Address - Street 1:819 E 11TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-3459
Practice Address - Country:US
Practice Address - Phone:850-769-7779
Practice Address - Fax:850-215-7718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid