Provider Demographics
NPI:1033617881
Name:SUPREME HOME LLC
Entity Type:Organization
Organization Name:SUPREME HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AJOKE
Authorized Official - Middle Name:OLOHIMA
Authorized Official - Last Name:WALKER KOLAWOLE
Authorized Official - Suffix:
Authorized Official - Credentials:BA, CNA
Authorized Official - Phone:907-830-6959
Mailing Address - Street 1:1735 MINERVA WAY
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-1490
Mailing Address - Country:US
Mailing Address - Phone:907-334-6468
Mailing Address - Fax:907-868-4670
Practice Address - Street 1:1735 MINERVA WAY
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-1490
Practice Address - Country:US
Practice Address - Phone:907-334-6468
Practice Address - Fax:907-868-4670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-26
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X, 3104A0630X
AK311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1030505Medicaid