Provider Demographics
NPI:1124602859
Name:SUPREME 6 LLC
Entity Type:Organization
Organization Name:SUPREME 6 LLC
Other - Org Name:BYNUM6 CARE HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:DAYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-417-1537
Mailing Address - Street 1:3800 COOPERSDALE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-3746
Mailing Address - Country:US
Mailing Address - Phone:704-999-8926
Mailing Address - Fax:
Practice Address - Street 1:3800 COOPERSDALE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-3746
Practice Address - Country:US
Practice Address - Phone:704-999-8926
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-09
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home