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General NPI Number Information
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NPI Number | 1285024539
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Entity Type | Organization
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Legal Business Name | SUPREME FAMILY CARE HOME
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Dates
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Enumeration Date | 01/26/2015
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Last Update Date | 01/26/2015
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Provider Practice Location Address
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Address Line | 1120 BENNING ST
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City | DURHAM
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State | NC
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Zip | 27703-1504
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Country | US
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Telephone | 919-997-3372
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Fax | 919-267-2662
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Provider Business Mailing Address
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Address Line | 1120 BENNING ST
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City | DURHAM
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State | NC
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Zip | 27703-1504
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Country | US
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Telephone | 919-997-3372
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Fax | 919-267-2662
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Authorized Official
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Title or Position | OWNER/ADMINISTRATOR
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Name | MRS. CHERYL GEORGE MITCHELL
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Credential |
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Telephone | 919-630-7103
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | FCL-032-137
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License Number State | NC
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