NPIMap

Organization Active NPI

Wise Choice Residential

  • Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
  • Conyers, GA
National Provider Identifier
1720319981
Registry record updated Jan 27, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual and/or Developmental Disabilities Community Based Residential Treatment FacilityTaxonomy code 320900000X
License
621960416A Issued in GA
Legal business name
WISE CHOICE RESIDENTIAL
Practice address
1040 Lake Haynes Dr NE
Conyers, GA 30012-1519
Phone
(770) 365-0578
Fax
(770) 679-4143
NPI assigned
Jan 27, 2010
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 27, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Fernando Leroy Favors
Title
Owner
Phone
(678) 409-5882

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility 320900000X 621960416A GA Primary

Addresses

Primary practice location

1040 Lake Haynes Dr NE
Conyers, GA 30012-1519

Mailing address

1040 Lake Haynes Dr NE
Conyers, GA 30012-1519
Phone (770) 365-0578

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1264550400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1264550400000",
    "number": "1720319981",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1040 LAKE HAYNES DR NE",
            "city": "CONYERS",
            "state": "GA",
            "postal_code": "300121519",
            "telephone_number": "770-365-0578",
            "fax_number": "770-679-4143"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1040 LAKE HAYNES DR NE",
            "city": "CONYERS",
            "state": "GA",
            "postal_code": "300121519",
            "telephone_number": "770-365-0578",
            "fax_number": "770-679-4143"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WISE CHOICE RESIDENTIAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-01-27",
        "last_updated": "2010-01-27",
        "status": "A",
        "authorized_official_last_name": "FAVORS",
        "authorized_official_first_name": "FERNANDO",
        "authorized_official_middle_name": "LEROY",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "678-409-5882",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "320900000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "GA",
            "license": "621960416A",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Conyers, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 27, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.