MEDICARE: SUPREME LEADERSHIP LLC

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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1679347637
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPREME LEADERSHIP LLC

Provider Business Mailing Address
First Line	:	2222 VAN BUREN ST APT 14
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33020-5176
Country	:	US
Telephone Number	:	407-350-7084
Fax Number	:

Provider Business Practice Location Address
First Line	:	2875 NE 191ST ST OFC 540
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33180-2801
Country	:	US
Telephone Number	:	786-733-3576
Fax Number	:

Authorized Official
Title or Position	:	FRANCHISE OWNER
Name	:	MR. RICARDO REY LOPEZ
Credential	:	MPH
Telephone Number	:	407-350-7084

Provider Enumeration Date	:	11/09/2023
Last Update Date	:	11/09/2023

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Directions to “SUPREME LEADERSHIP LLC ” Practice Location

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