MEDICARE: SUPREME RECOVERY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1053686139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPREME RECOVERY INC

Provider Business Mailing Address
First Line	:	5420 SW 133RD CT
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33175-6149
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5420 SW 133RD CT
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33175-6149
Country	:	US
Telephone Number	:	786-246-0539
Fax Number	:	786-558-3382

Authorized Official
Title or Position	:	PRESIDENT
Name	:	EDURARDO GONZALEZ
Credential	:
Telephone Number	:	786-216-5570

Provider Enumeration Date	:	03/21/2012
Last Update Date	:	03/21/2012

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Directions to “SUPREME RECOVERY INC ” Practice Location

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