Healthcare Provider Details

I. General information

NPI: 1770039166
Provider Name (Legal Business Name): SUPREME MEMORY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11750 PADON RD
NEEDVILLE TX
77461-9681
US

IV. Provider business mailing address

11750 PADON RD
NEEDVILLE TX
77461-9681
US

V. Phone/Fax

Practice location:
  • Phone: 832-282-7363
  • Fax:
Mailing address:
  • Phone: 832-282-7363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number106501
License Number StateTX

VIII. Authorized Official

Name: ELIZABETH WILLIAMS
Title or Position: DIRECTOR
Credential:
Phone: 832-282-7363