MEDICARE: SUPREME S&S CARE DKS, 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1235068933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPREME S&S CARE DKS, LLC

Provider Business Mailing Address
First Line	:	913 POPLAR COVE WAY
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23223-2150
Country	:	US
Telephone Number	:	804-687-9427
Fax Number	:	804-486-6620

Provider Business Practice Location Address
First Line	:	2905 SANDY LN
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23223-2119
Country	:	US
Telephone Number	:	804-869-3732
Fax Number	:	804-486-6620

Authorized Official
Title or Position	:	OWNER
Name	:	KATRINA SABRINA SAMUELS
Credential	:
Telephone Number	:	804-687-9427

Provider Enumeration Date	:	05/18/2026
Last Update Date	:	05/18/2026

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