Healthcare Provider Details

I. General information

NPI: 1235068933
Provider Name (Legal Business Name): SUPREME S&S CARE DKS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 SANDY LN
RICHMOND VA
23223-2119
US

IV. Provider business mailing address

913 POPLAR COVE WAY
RICHMOND VA
23223-2150
US

V. Phone/Fax

Practice location:
  • Phone: 804-869-3732
  • Fax: 804-486-6620
Mailing address:
  • Phone: 804-687-9427
  • Fax: 804-486-6620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: KATRINA SABRINA SAMUELS
Title or Position: OWNER
Credential:
Phone: 804-687-9427