Healthcare Provider Details

I. General information

NPI: 1982175154
Provider Name (Legal Business Name): SUPREME NURSING CARE AND SUPPORTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 MARLTON PIKE E STE 22A
CHERRY HILL NJ
08034-2207
US

IV. Provider business mailing address

1101 W HAMILTON ST STE 141
ALLENTOWN PA
18101-1043
US

V. Phone/Fax

Practice location:
  • Phone: 614-929-1931
  • Fax:
Mailing address:
  • Phone: 614-929-1931
  • 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 Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MR. MOHAMED BABA FOFANAH
Title or Position: CEO
Credential: MPH
Phone: 614-929-1931