Provider Demographics
NPI:1386975548
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:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETHENA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACKOSN
Authorized Official - Suffix:
Authorized Official - Credentials:BA, CSAC
Authorized Official - Phone:919-682-4771
Mailing Address - Street 1:930 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-2656
Mailing Address - Country:US
Mailing Address - Phone:919-633-8360
Mailing Address - Fax:919-683-2641
Practice Address - Street 1:976 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-2654
Practice Address - Country:US
Practice Address - Phone:919-633-8360
Practice Address - Fax:919-683-2641
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW OUTLOOK..SECOND CHANCE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-27
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302362GMedicaid
NC8700391Medicaid
NC8302362BMedicaid
NC8302703GMedicaid
NC8302703BMedicaid