Healthcare Provider Details

I. General information

NPI: 1972591311
Provider Name (Legal Business Name): SUPPLEMENTAL PROFESSIONAL RESOURCES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3976 LOCKPORT OLCOTT RD
LOCKPORT NY
14094-1133
US

IV. Provider business mailing address

3976 LOCKPORT OLCOTT RD
LOCKPORT NY
14094-1133
US

V. Phone/Fax

Practice location:
  • Phone: 716-433-7810
  • Fax: 716-433-7811
Mailing address:
  • Phone: 716-433-7810
  • Fax: 716-433-7811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number9969L001
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number9969L001
License Number StateNY

VIII. Authorized Official

Name: MR. DONALD L KEPNER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 716-514-5527