Provider Demographics
NPI:1326631862
Name:SUPREME HEALTHCARE PLLC
Entity Type:Organization
Organization Name:SUPREME HEALTHCARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KANDY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:KEENEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-845-5498
Mailing Address - Street 1:9521 RIVERSIDE PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-7422
Mailing Address - Country:US
Mailing Address - Phone:918-845-5498
Mailing Address - Fax:
Practice Address - Street 1:4619 S HARVARD AVE STE 100
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2921
Practice Address - Country:US
Practice Address - Phone:918-619-9441
Practice Address - Fax:918-619-9442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-16
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200993730Medicaid