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General NPI Number Information
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NPI Number | 1629779194
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Entity Type | Organization
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Legal Business Name | SUPREME CARE HOUSING LLC
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Dates
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Enumeration Date | 03/13/2023
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Last Update Date | 03/13/2023
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Provider Practice Location Address
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Address Line | 334 BETSY AVE SW
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City | ATLANTA
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State | GA
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Zip | 30310-1008
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Country | US
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Telephone | 770-585-3029
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Fax |
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Provider Business Mailing Address
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Address Line | 3379 PEACHTREE RD NE STE 555
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City | ATLANTA
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State | GA
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Zip | 30326-1418
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Country | US
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Telephone | 770-585-3029
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DORIS LOGAN
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Credential |
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Telephone | 770-585-3029
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 347C00000X
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Taxonomy Name | Private Vehicle
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 3104A0630X
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Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
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License Number |
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License Number State |
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Taxonomy #5
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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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Taxonomy #6
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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