Provider Demographics
NPI:1477543890
Name:WISE LIFE CARE, LLC
Entity Type:Organization
Organization Name:WISE LIFE CARE, LLC
Other - Org Name:HERITAGE HALL - WISE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CCO & GENERAL COUNSEL
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAINES
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:540-774-4263
Mailing Address - Street 1:3131 ELECTRIC RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-6427
Mailing Address - Country:US
Mailing Address - Phone:540-774-4263
Mailing Address - Fax:540-774-0780
Practice Address - Street 1:9434 COEBURN MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:WISE
Practice Address - State:VA
Practice Address - Zip Code:24293
Practice Address - Country:US
Practice Address - Phone:276-328-2721
Practice Address - Fax:276-328-1463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANH2583314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4953509Medicaid
VA200515608OtherFEDERAL BLACK LUNG ID
VA180512OtherANTHEM BCBS PROVIDER ID
VA495350Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID