Provider Demographics
NPI:1730692252
Name:2ND CHANCE AT LIFE, LLC
Entity type:Organization
Organization Name:2ND CHANCE AT LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NATHALIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:GILLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-270-9745
Mailing Address - Street 1:5711 NW 21ST ST APT 18B
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33313-3108
Mailing Address - Country:US
Mailing Address - Phone:239-270-9745
Mailing Address - Fax:
Practice Address - Street 1:10425 NW 2ND CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33150-1128
Practice Address - Country:US
Practice Address - Phone:786-281-2086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty