MEDICARE: SUPREME INTERVENTION CENTER

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	261QA0600X	Adult Day Care Clinic/Center	2500	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1627836	OTHER	LA	ADULT DAY HEALTH CARE

General Provider Information

NPI Number	:	1154428373
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPREME INTERVENTION CENTER

Provider Business Mailing Address
First Line	:	PO BOX 3141
Second Line	:
City	:	MONROE
State	:	LA
Zip	:	71210-3141
Country	:	US
Telephone Number	:	318-323-4710
Fax Number	:	318-323-3855

Provider Business Practice Location Address
First Line	:	1114 JACKSON ST
Second Line	:
City	:	MONROE
State	:	LA
Zip	:	71202-2024
Country	:	US
Telephone Number	:	318-323-4710
Fax Number	:	318-323-3855

Authorized Official
Title or Position	:	TRUSTEE
Name	:	MRS. EMILY B. WINSTON
Credential	:	R.N.
Telephone Number	:	318-325-8863

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	08/22/2020

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Directions to “SUPREME INTERVENTION CENTER ” Practice Location

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