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General NPI Number Information
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NPI Number | 1326631862
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Entity Type | Organization
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Legal Business Name | SUPREME HEALTHCARE PLLC
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Dates
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Enumeration Date | 02/16/2021
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Last Update Date | 12/15/2021
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Provider Practice Location Address
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Address Line | 4619 S HARVARD AVE STE 100
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City | TULSA
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State | OK
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Zip | 74135-2921
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Country | US
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Telephone | 918-619-9441
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Fax | 918-619-9442
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Provider Business Mailing Address
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Address Line | 9521 RIVERSIDE PKWY STE B
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City | TULSA
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State | OK
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Zip | 74137-7422
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Country | US
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Telephone | 918-845-5498
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MRS. KANDY KAY KEENEY
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Credential |
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Telephone | 918-845-5498
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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