Provider Demographics
NPI:1083379564
Name:SUPRA MEDICAL GROUP II, LLC
Entity Type:Organization
Organization Name:SUPRA MEDICAL GROUP II, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KLEYDSON
Authorized Official - Middle Name:
Authorized Official - Last Name:DA SILVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-200-5210
Mailing Address - Street 1:10300 SW 72ND ST STE 101
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-3038
Mailing Address - Country:US
Mailing Address - Phone:305-200-5210
Mailing Address - Fax:305-200-5780
Practice Address - Street 1:10300 SW 72ND ST STE 101
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3038
Practice Address - Country:US
Practice Address - Phone:305-200-5210
Practice Address - Fax:305-200-5780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care