MEDICARE: SUPRA HOME HEALTH, INC.

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	251E00000X	Home Health Agency	299992774	FL

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
2	299992774	OTHER	FL	LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922209162
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPRA HOME HEALTH, INC.

Provider Business Mailing Address
First Line	:	6720 TAFT ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33024-3903
Country	:	US
Telephone Number	:	954-443-6461
Fax Number	:	954-443-6462

Provider Business Practice Location Address
First Line	:	6720 TAFT ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33024-3903
Country	:	US
Telephone Number	:	954-443-6461
Fax Number	:	954-443-6462

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. DAVEL PRIETO
Credential	:
Telephone Number	:	954-443-6461

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	04/17/2020

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Directions to “SUPRA HOME HEALTH, INC. ” Practice Location

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