=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558795765
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WISDOM ADULT DAY CARE SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2013
-----------------------------------------------------
Last Update Date | 08/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1197 GLADE RD
-----------------------------------------------------
City | HAVANA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32333-3618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-539-8485
-----------------------------------------------------
Fax | 850-539-8486
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1747 FL GA HWY
-----------------------------------------------------
City | HAVANA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32333-4591
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-539-8485
-----------------------------------------------------
Fax | 850-539-8486
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | LATASHA DAVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-539-8485
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | 9251
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------