=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477627115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPREME REHAB INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2006
-----------------------------------------------------
Last Update Date | 04/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29930 W 12 MILE RD STE 3
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48334-3983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-862-2512
-----------------------------------------------------
Fax | 248-862-2145
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29930 W 12 MILE RD STE 3
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48334-3983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-862-2512
-----------------------------------------------------
Fax | 248-862-2145
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / ADMINISTRATOR
-----------------------------------------------------
Name | NASEEM AHMED KHAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-214-1234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 4105160001
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 638089
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------