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General NPI Number Information
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NPI Number | 1104792183
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Entity Type | Organization
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Legal Business Name | SUPREME CARE SERVICESLLC
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Dates
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Enumeration Date | 10/15/2025
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Last Update Date | 12/08/2025
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Provider Practice Location Address
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Address Line | 4738 68TH AVE
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City | HYATTSVILLE
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State | MD
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Zip | 20784-1400
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Country | US
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Telephone | 301-814-1509
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Fax | 301-814-1509
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Provider Business Mailing Address
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Address Line | 4738 68TH AVE
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City | HYATTSVILLE
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State | MD
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Zip | 20784-1400
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Country | US
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Telephone | 301-814-1509
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Fax | 301-814-1509
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Authorized Official
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Title or Position | PRESIDENT
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Name | KORPO KOLLIE JOHNSON
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Credential | NURSE
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Telephone | 301-814-1509
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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