MEDICARE: SUPREME HEALTHCARE SERVICES, 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	311Z00000X	Custodial Care Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871864124
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPREME HEALTHCARE SERVICES, LLC

Provider Business Mailing Address
First Line	:	6475 NEW HAMPSHIRE AVE
Second Line	:	SUITE 315
City	:	HYATTSVILLE
State	:	MD
Zip	:	20783-3282
Country	:	US
Telephone Number	:	240-357-8763
Fax Number	:	240-863-3313

Provider Business Practice Location Address
First Line	:	4611 CLAY ST NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20019-4663
Country	:	US
Telephone Number	:	240-357-8763
Fax Number	:	240-863-3313

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MS. GANIYAT FUNMI EFUNTOYE
Credential	:
Telephone Number	:	240-357-8763

Provider Enumeration Date	:	01/18/2012
Last Update Date	:	05/11/2017

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