MEDICARE: SUPAM 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

General Provider Information

NPI Number	:	1104118884
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPAM LLC

Provider Business Mailing Address
First Line	:	5419 N LOVINGTON HWY
Second Line	:	SUITE 7
City	:	HOBBS
State	:	NM
Zip	:	88240-9100
Country	:	US
Telephone Number	:	575-392-3903
Fax Number	:	575-392-3911

Provider Business Practice Location Address
First Line	:	5419 NORTH LOVINGTON HIGHWAY
Second Line	:	SUITE 7
City	:	HOBBS
State	:	NM
Zip	:	88240-9135
Country	:	US
Telephone Number	:	575-392-3903
Fax Number	:	575-392-3911

Authorized Official
Title or Position	:	OWNER
Name	:	MUKESHBHAI B PATEL
Credential	:	MD
Telephone Number	:	732-713-2824

Provider Enumeration Date	:	05/12/2011
Last Update Date	:	03/01/2012

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