Healthcare Provider Details

I. General information

NPI: 1629779194
Provider Name (Legal Business Name): SUPREME CARE HOUSING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 BETSY AVE SW
ATLANTA GA
30310-1008
US

IV. Provider business mailing address

3379 PEACHTREE RD NE STE 555
ATLANTA GA
30326-1418
US

V. Phone/Fax

Practice location:
  • Phone: 770-585-3029
  • Fax:
Mailing address:
  • Phone: 770-585-3029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: DORIS LOGAN
Title or Position: CEO
Credential:
Phone: 770-585-3029