Healthcare Provider Details

I. General information

NPI: 1245013580
Provider Name (Legal Business Name): SUPREME RESIDENTIAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2023
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 ROCHE DR
DURHAM NC
27703
US

IV. Provider business mailing address

315 ROCHE DR
DURHAM NC
27703
US

V. Phone/Fax

Practice location:
  • Phone: 919-482-8299
  • Fax:
Mailing address:
  • Phone: 919-482-8299
  • 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 Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JOHN CHAMBERS
Title or Position: OWNER
Credential:
Phone: 919-482-8299