Healthcare Provider Details

I. General information

NPI: 1003182155
Provider Name (Legal Business Name): SUPREME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2849 GEORGIA AVE NW SUITE 2
WASHINGTON DC
20001-5600
US

IV. Provider business mailing address

2849 GEORGIA AVE NW SUITE 2
WASHINGTON DC
20001-5600
US

V. Phone/Fax

Practice location:
  • Phone: 202-525-2175
  • Fax: 202-525-2177
Mailing address:
  • Phone: 202-525-2175
  • Fax: 202-525-2177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: AGNES MASAWE
Title or Position: PRESIDENT
Credential:
Phone: 202-255-2574