Provider Demographics
| NPI: | 1386838571 |
|---|---|
| Name: | SUPREME HEALTH CARE SERVICES |
| Entity Type: | Organization |
| Organization Name: | SUPREME HEALTH CARE SERVICES |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | PROGRAM DIRECTOR |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | JOHN |
| Authorized Official - Middle Name: | OMONKHUALE |
| Authorized Official - Last Name: | MADOJEMU |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MSM, PHD (C) |
| Authorized Official - Phone: | 757-393-0327 |
| Mailing Address - Street 1: | 3300 TYRE NECK ROAD |
| Mailing Address - Street 2: | SUITE F |
| Mailing Address - City: | PORTSMOUTH |
| Mailing Address - State: | VA |
| Mailing Address - Zip Code: | 23703-3319 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 757-393-0327 |
| Mailing Address - Fax: | 757-393-0328 |
| Practice Address - Street 1: | 3300 TYRE NECK ROAD |
| Practice Address - Street 2: | SUITE F |
| Practice Address - City: | PORTSMOUTH |
| Practice Address - State: | VA |
| Practice Address - Zip Code: | 23703-3319 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 757-393-0327 |
| Practice Address - Fax: | 757-393-0328 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2007-08-30 |
| Last Update Date: | 2012-08-03 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 251E00000X | Agencies | Home Health | |
| No | 251C00000X | Agencies | Day Training, Developmentally Disabled Services | |
| No | 251F00000X | Agencies | Home Infusion | |
| No | 251G00000X | Agencies | Hospice Care, Community Based | |
| No | 251J00000X | Agencies | Nursing Care | |
| No | 310400000X | Nursing & Custodial Care Facilities | Assisted Living Facility | |
| No | 3104A0625X | Nursing & Custodial Care Facilities | Assisted Living Facility | Assisted Living, Mental Illness |
| No | 311Z00000X | Nursing & Custodial Care Facilities | Custodial Care Facility | |
| No | 311ZA0620X | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
| No | 314000000X | Nursing & Custodial Care Facilities | Skilled Nursing Facility | |
| No | 3140N1450X | Nursing & Custodial Care Facilities | Skilled Nursing Facility | Nursing Care, Pediatric |
| No | 315P00000X | Nursing & Custodial Care Facilities | Intermediate Care Facility, Intellectual Disabilities | |
| No | 385HR2055X | Respite Care Facility | Respite Care | Respite Care, Mental Illness, Child |
| No | 385HR2060X | Respite Care Facility | Respite Care | Respite Care, Intellectual and/or Developmental Disabilities, Child |
| No | 385HR2065X | Respite Care Facility | Respite Care | Respite Care, Physical Disabilities, Child |
