Provider Demographics
NPI:1053139394
Name:SAN DIEGO SECOND CHANCE PROGRAM
Entity type:Organization
Organization Name:SAN DIEGO SECOND CHANCE PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR & CEO
Authorized Official - Prefix:
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-234-8888
Mailing Address - Street 1:6145 IMPERIAL AVE
Mailing Address - Street 2:CENTRAL DRUG COURT
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-4213
Mailing Address - Country:US
Mailing Address - Phone:619-234-8888
Mailing Address - Fax:619-234-7787
Practice Address - Street 1:6145 IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-4213
Practice Address - Country:US
Practice Address - Phone:619-234-8888
Practice Address - Fax:619-234-7787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health