Healthcare Provider Details

I. General information

NPI: 1780510867
Provider Name (Legal Business Name): SUPREME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2232 W BROADWAY APT 415
MONONA WI
53713-1613
US

IV. Provider business mailing address

2232 W BROADWAY APT 415
MONONA WI
53713-1613
US

V. Phone/Fax

Practice location:
  • Phone: 612-644-8552
  • Fax:
Mailing address:
  • Phone: 612-644-8552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: FADUMO HUSEIN
Title or Position: OWNER
Credential:
Phone: 612-644-8552