Provider Demographics
NPI:1144409640
Name:SUPPLEMENTAL HEALTHCARE
Entity Type:Organization
Organization Name:SUPPLEMENTAL HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:ADGER
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:JR
Authorized Official - Credentials:PTA
Authorized Official - Phone:864-764-5189
Mailing Address - Street 1:6033 BROOKGREEN CT
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-3547
Mailing Address - Country:US
Mailing Address - Phone:864-764-5189
Mailing Address - Fax:
Practice Address - Street 1:6033 BROOKGREEN CT
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-3547
Practice Address - Country:US
Practice Address - Phone:864-764-5189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1931251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health