1902056153 NPI number — SUPREME HOME CARE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902056153 NPI number — SUPREME HOME CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPREME HOME CARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902056153
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2010 WOODMERE BLVD
Provider Second Line Business Mailing Address:
STE B
Provider Business Mailing Address City Name:
HARVEY
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70058
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-340-9313
Provider Business Mailing Address Fax Number:
504-340-9314

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2010 WOODMERE BLVD
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
HARVEY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70058-2286
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-340-9313
Provider Business Practice Location Address Fax Number:
504-340-9314
Provider Enumeration Date:
09/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RILEY
Authorized Official First Name:
DENISE
Authorized Official Middle Name:
CAREY
Authorized Official Title or Position:
CHIEF ADMINISTRATOR
Authorized Official Telephone Number:
504-340-9313

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X , with the licence number:  PCA15107 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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