MEDICARE: SUPREME SENIOR LIVING, 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	347C00000X	Private Vehicle
2	311ZA0620X	Adult Care Home Facility

General Provider Information

NPI Number	:	1801351770
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPREME SENIOR LIVING, LLC

Provider Business Mailing Address
First Line	:	502 SOUTHRIDGE RD FL 34711USA
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34711-6487
Country	:	US
Telephone Number	:	407-929-7247
Fax Number	:

Provider Business Practice Location Address
First Line	:	502 SOUTHRIDGE RD FL 34711USA
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34711-6487
Country	:	US
Telephone Number	:	407-929-7247
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	AMOY YOUNG
Credential	:
Telephone Number	:	407-929-7247

Provider Enumeration Date	:	02/05/2019
Last Update Date	:	04/08/2026

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