Provider Demographics
NPI:1306350178
Name:LIVING HOPE SECOND CHANCE LLC
Entity type:Organization
Organization Name:LIVING HOPE SECOND CHANCE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAVIA
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-203-4535
Mailing Address - Street 1:20455 CYPRESS DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-7319
Mailing Address - Country:US
Mailing Address - Phone:612-203-4535
Mailing Address - Fax:952-217-4427
Practice Address - Street 1:7400 METRO BLVD STE 230
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2352
Practice Address - Country:US
Practice Address - Phone:612-203-4535
Practice Address - Fax:952-217-4427
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIVING HOPE SECOND CHANCE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-30
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No174200000XOther Service ProvidersMealsGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
No251300000XAgenciesLocal Education Agency (LEA)Group - Single Specialty
No251E00000XAgenciesHome HealthGroup - Multi-Specialty
No332U00000XSuppliersHome Delivered MealsGroup - Multi-Specialty
No342000000XTransportation ServicesTransportation Network Company
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No385H00000XRespite Care FacilityRespite Care
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1306350178Medicaid
MN1306350178OtherANY HEALTHCARE RELATED IDENTIFIERS