Healthcare Provider Details

I. General information

NPI: 1801351770
Provider Name (Legal Business Name): SUPREME SENIOR LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2019
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 SOUTHRIDGE RD FL 34711USA
CLERMONT FL
34711-6487
US

IV. Provider business mailing address

502 SOUTHRIDGE RD FL 34711USA
CLERMONT FL
34711-6487
US

V. Phone/Fax

Practice location:
  • Phone: 407-929-7247
  • Fax:
Mailing address:
  • Phone: 407-929-7247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: AMOY YOUNG
Title or Position: ADMINISTRATOR
Credential:
Phone: 407-929-7247