MEDICARE: SUPREME CARE SERVICESLLC

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1104792183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPREME CARE SERVICESLLC

Provider Business Mailing Address
First Line	:	4738 68TH AVE
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20784-1400
Country	:	US
Telephone Number	:	301-814-1509
Fax Number	:	301-814-1509

Provider Business Practice Location Address
First Line	:	4738 68TH AVE
Second Line	:
City	:	HYATTSVILLE
State	:	MD
Zip	:	20784-1400
Country	:	US
Telephone Number	:	301-814-1509
Fax Number	:	301-814-1509

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KORPO KOLLIE JOHNSON
Credential	:	NURSE
Telephone Number	:	301-814-1509

Provider Enumeration Date	:	10/15/2025
Last Update Date	:	12/08/2025

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