Provider Demographics
NPI:1558795765
Name:WISDOM ADULT DAY CARE SERVICES, LLC
Entity Type:Organization
Organization Name:WISDOM ADULT DAY CARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LATASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-539-8485
Mailing Address - Street 1:1747 FL GA HWY
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:FL
Mailing Address - Zip Code:32333-4591
Mailing Address - Country:US
Mailing Address - Phone:850-539-8485
Mailing Address - Fax:850-539-8486
Practice Address - Street 1:1197 GLADE RD
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:FL
Practice Address - Zip Code:32333-3618
Practice Address - Country:US
Practice Address - Phone:850-539-8485
Practice Address - Fax:850-539-8486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9251305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service