Healthcare Provider Details

I. General information

NPI: 1013886779
Provider Name (Legal Business Name): SUPREME WELLCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2025
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 GATES MILL DR
LAWRENCEVILLE GA
30045-7190
US

IV. Provider business mailing address

161 GATES MILL DR
LAWRENCEVILLE GA
30045-7190
US

V. Phone/Fax

Practice location:
  • Phone: 678-886-9604
  • Fax:
Mailing address:
  • Phone: 678-886-9604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: FIDELIS AIGBADON
Title or Position: OWNER
Credential:
Phone: 678-886-9604