Provider Demographics
NPI:1720319981
Name:WISE CHOICE RESIDENTIAL
Entity Type:Organization
Organization Name:WISE CHOICE RESIDENTIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:FAVORS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-409-5882
Mailing Address - Street 1:1040 LAKE HAYNES DR NE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-1519
Mailing Address - Country:US
Mailing Address - Phone:770-365-0578
Mailing Address - Fax:770-679-4143
Practice Address - Street 1:1040 LAKE HAYNES DR NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-1519
Practice Address - Country:US
Practice Address - Phone:770-365-0578
Practice Address - Fax:770-679-4143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA621960416A320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities