Provider Demographics
NPI:1083326169
Name:WISE FUTURE GROUP SUPPORT SERVICES, LLC
Entity Type:Organization
Organization Name:WISE FUTURE GROUP SUPPORT SERVICES, LLC
Other - Org Name:WISE FUTURE GROUP SUPPORT SERVICES LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:YAZNELLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-508-7374
Mailing Address - Street 1:10244 E COLONIAL DR STE 110
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-4365
Mailing Address - Country:US
Mailing Address - Phone:407-202-9440
Mailing Address - Fax:
Practice Address - Street 1:10244 E COLONIAL DR STE 110
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-4365
Practice Address - Country:US
Practice Address - Phone:407-508-7374
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-20
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110561900Medicaid