Healthcare Provider Details

I. General information

NPI: 1104792183
Provider Name (Legal Business Name): SUPREME CARE SERVICESLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4738 68TH AVE
HYATTSVILLE MD
20784-1400
US

IV. Provider business mailing address

4738 68TH AVE
HYATTSVILLE MD
20784-1400
US

V. Phone/Fax

Practice location:
  • Phone: 301-814-1509
  • Fax: 301-814-1509
Mailing address:
  • Phone: 301-814-1509
  • Fax: 301-814-1509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: KORPO KOLLIE JOHNSON
Title or Position: PRESIDENT
Credential: NURSE
Phone: 301-814-1509