Provider Demographics
NPI:1366629610
Name:WISE ENTERPRISE, INCORPORATED
Entity Type:Organization
Organization Name:WISE ENTERPRISE, INCORPORATED
Other - Org Name:WISE ENTERPRISE, INCORPORATED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:VERONICA
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:804-986-8214
Mailing Address - Street 1:3109 W CLAY ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-4703
Mailing Address - Country:US
Mailing Address - Phone:804-301-3513
Mailing Address - Fax:
Practice Address - Street 1:4895 BURNHAM RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23234-3711
Practice Address - Country:US
Practice Address - Phone:804-986-8214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA973-02-029251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization