# WISTERIA ELDERLY CARE, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1154664043
- **Authorized official:** MRS. WITZA LARIONNE (OWNER)
- **Authorized official phone:** (321) 345-4177

## Contact information

- **Practice address:** 189 DONALD AVE NE, PALM BAY, FL 32907-3158
- **Practice address phone:** (321) 345-4177
- **Practice address fax:** (321) 345-4177
- **Mailing address:** 189 DONALD AVE NE, PALM BAY, FL 32907-3158
- **Mailing address phone:** (321) 345-4177
- **Mailing address fax:** (321) 345-4177

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 347C00000X | Private Vehicle | 232475 | FL | — |
| 385H00000X | Respite Care | 6906533 | FL | Yes |

## Other

- **Enumeration date:** 03/29/2013
- **Last updated:** 03/29/2013