MEDICARE: SUPREME MEDICAL CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center
2	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1023573805
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPREME MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	8109 ANTOINE DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77088-2801
Country	:	US
Telephone Number	:	281-975-8182
Fax Number	:	844-258-8747

Provider Business Practice Location Address
First Line	:	8109 ANTOINE DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77088-2801
Country	:	US
Telephone Number	:	844-245-8747
Fax Number	:	844-258-8747

Authorized Official
Title or Position	:	OWNER
Name	:	BRITTANY GREEN
Credential	:
Telephone Number	:	281-975-8182

Provider Enumeration Date	:	02/05/2019
Last Update Date	:	11/04/2024

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