Provider Demographics
NPI:1881107118
Name:WISBA HOME CARE AND PROFESSIONAL CAREER CENTER LLC
Entity type:Organization
Organization Name:WISBA HOME CARE AND PROFESSIONAL CAREER CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINISTRATOR CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:BASTIA
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:678-425-4030
Mailing Address - Street 1:PO BOX 1915
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30156-8915
Mailing Address - Country:US
Mailing Address - Phone:678-696-9905
Mailing Address - Fax:800-410-2504
Practice Address - Street 1:2220 ATLANTA RD SE STE 103
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-1541
Practice Address - Country:US
Practice Address - Phone:800-413-9066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-08
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033-R-1532253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care