Healthcare Provider Details

I. General information

NPI: 1477543890
Provider Name (Legal Business Name): WISE LIFE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9434 COEBURN MOUNTAIN RD
WISE VA
24293
US

IV. Provider business mailing address

3131 ELECTRIC RD
ROANOKE VA
24018-6427
US

V. Phone/Fax

Practice location:
  • Phone: 276-328-2721
  • Fax: 276-328-1463
Mailing address:
  • Phone: 540-774-4263
  • Fax: 540-774-0780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH2583
License Number StateVA

VIII. Authorized Official

Name: CASSANDRA GALLANT
Title or Position: COMPLIANCE & PRIVACY OFFICER
Credential:
Phone: 540-774-4263