=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548793771
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE WISDOM WAY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2017
-----------------------------------------------------
Last Update Date | 04/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 E PALMETTO PARK RD STE 800
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33432-4833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-298-4332
-----------------------------------------------------
Fax | 561-465-7616
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 E PALMETTO PARK RD STE 800
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33432-4833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-298-4332
-----------------------------------------------------
Fax | 561-465-7616
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MONIQUE JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-298-4332
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 234707
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------