Healthcare Provider Details

I. General information

NPI: 1477627115
Provider Name (Legal Business Name): SUPREME REHAB INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 04/16/2022
Certification Date: 04/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29930 W 12 MILE RD STE 3
FARMINGTON HILLS MI
48334-3983
US

IV. Provider business mailing address

29930 W 12 MILE RD STE 3
FARMINGTON HILLS MI
48334-3983
US

V. Phone/Fax

Practice location:
  • Phone: 248-862-2512
  • Fax: 248-862-2145
Mailing address:
  • Phone: 248-862-2512
  • Fax: 248-862-2145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number638089
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4105160001
License Number StateMI

VIII. Authorized Official

Name: NASEEM AHMED KHAN
Title or Position: OWNER / ADMINISTRATOR
Credential:
Phone: 248-214-1234