Healthcare Provider Details

I. General information

NPI: 1326925447
Provider Name (Legal Business Name): ESL SUPREME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2025
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 WESTGATE DR UNIT 7/8
BROCKTON MA
02301-1822
US

IV. Provider business mailing address

365 WESTGATE DR UNIT 7/8
BROCKTON MA
02301-1822
US

V. Phone/Fax

Practice location:
  • Phone: 646-470-9456
  • Fax:
Mailing address:
  • Phone: 646-470-9456
  • Fax:

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: FRANTZ BERTHIE SUPREME VAL
Title or Position: CO-EXECUTIVE DIRECTOR
Credential:
Phone: 407-946-1009