Provider Demographics
NPI:1275076580
Name:SUPREME HOME CARE AGENCY OF NY INC
Entity Type:Organization
Organization Name:SUPREME HOME CARE AGENCY OF NY INC
Other - Org Name:NU HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YOUNGSOON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-888-0855
Mailing Address - Street 1:4108 163RD ST FL 2
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-2669
Mailing Address - Country:US
Mailing Address - Phone:718-888-0855
Mailing Address - Fax:718-353-9212
Practice Address - Street 1:4108 163RD ST FL 2
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-2669
Practice Address - Country:US
Practice Address - Phone:718-888-0855
Practice Address - Fax:718-353-9212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-18
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1935L001251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04505657Medicaid