Healthcare Provider Details

I. General information

NPI: 1164574711
Provider Name (Legal Business Name): SUPPLEMENTAL HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6849 PEACHTREE DUNWOODY RD NE NE ST. 102 BLDG B1
ATLANTA GA
30328-1610
US

IV. Provider business mailing address

1640 WEST REDSTONE CENTER DRIVE SUITE 200
PARK CITY UT
84098
US

V. Phone/Fax

Practice location:
  • Phone: 866-587-9922
  • Fax: 678-587-9993
Mailing address:
  • Phone: 800-456-6677
  • Fax: 435-776-7281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number56131
License Number StateGA

VIII. Authorized Official

Name: MIKE JACOUTOT
Title or Position: CEO
Credential:
Phone: 800-456-6677