Provider Demographics
NPI:1215019757
Name:SUPREME MEDICAL &SURGICAL EQUIPMENT SUPPLY LLC
Entity Type:Organization
Organization Name:SUPREME MEDICAL &SURGICAL EQUIPMENT SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:IDEMUDIA
Authorized Official - Last Name:IGIEHON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-399-4009
Mailing Address - Street 1:PO BOX 6355
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07106-0355
Mailing Address - Country:US
Mailing Address - Phone:973-399-4009
Mailing Address - Fax:973-399-4033
Practice Address - Street 1:1230 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-1982
Practice Address - Country:US
Practice Address - Phone:973-399-4009
Practice Address - Fax:973-399-4033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5409870001Medicare ID - Type Unspecified