Provider Demographics
NPI:1588391734
Name:SECOND CHANCE MINISERIES WELKLNESS CENTER
Entity type:Organization
Organization Name:SECOND CHANCE MINISERIES WELKLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:
Authorized Official - First Name:COREY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:PYSD
Authorized Official - Phone:916-893-4528
Mailing Address - Street 1:289 N 19TH AVE APT 52
Mailing Address - Street 2:
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93245-2573
Mailing Address - Country:US
Mailing Address - Phone:805-800-8209
Mailing Address - Fax:
Practice Address - Street 1:289 N 19TH AVE APT 52
Practice Address - Street 2:
Practice Address - City:LEMOORE
Practice Address - State:CA
Practice Address - Zip Code:93245-2573
Practice Address - Country:US
Practice Address - Phone:805-800-8209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-06
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty