Provider Demographics
NPI:1154085181
Name:SUPREME LIVING LLC
Entity Type:Organization
Organization Name:SUPREME LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RINALDO
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:360-639-7002
Mailing Address - Street 1:1420 MARVIN ROAD NE
Mailing Address - Street 2:STE C-347
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516
Mailing Address - Country:US
Mailing Address - Phone:206-947-4353
Mailing Address - Fax:
Practice Address - Street 1:6604 MARTIN WAY E
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98516
Practice Address - Country:US
Practice Address - Phone:360-362-7002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-26
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2171006Medicaid