Provider Demographics
NPI:1164574711
Name:SUPPLEMENTAL HEALTH CARE
Entity Type:Organization
Organization Name:SUPPLEMENTAL HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOUTOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-456-6677
Mailing Address - Street 1:1640 WEST REDSTONE CENTER DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098
Mailing Address - Country:US
Mailing Address - Phone:800-456-6677
Mailing Address - Fax:435-776-7281
Practice Address - Street 1:6849 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:NE ST. 102 BLDG B1
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-1610
Practice Address - Country:US
Practice Address - Phone:866-587-9922
Practice Address - Fax:678-587-9993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA56131251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care