Provider Demographics
NPI:1396344800
Name:WISE HOLDINGS LLC
Entity type:Organization
Organization Name:WISE HOLDINGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CALLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-564-2270
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-0520
Mailing Address - Country:US
Mailing Address - Phone:918-564-2270
Mailing Address - Fax:877-210-2506
Practice Address - Street 1:500 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-3818
Practice Address - Country:US
Practice Address - Phone:918-564-2270
Practice Address - Fax:877-210-2506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-26
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty