MEDICARE: GINOU SUPRE

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	RN9550663	FL
2	163W00000X	Registered Nurse	RN9550663	FL

General Provider Information

NPI Number	:	1932063310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINOU SUPRE

Provider Business Mailing Address
First Line	:	23240 FITZPATRICK AVE
Second Line	:
City	:	PUNTA GORDA
State	:	FL
Zip	:	33980-5730
Country	:	US
Telephone Number	:	239-601-2058
Fax Number	:

Provider Business Practice Location Address
First Line	:	23240 FITZPATRICK AVE
Second Line	:
City	:	PUNTA GORDA
State	:	FL
Zip	:	33980-5730
Country	:	US
Telephone Number	:	239-601-2058
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/10/2025
Last Update Date	:	12/10/2025

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Directions to “ GINOU SUPRE ” Practice Location

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