Provider Demographics
NPI:1477627115
Name:SUPREME REHAB INC
Entity Type:Organization
Organization Name:SUPREME REHAB INC
Other - Org Name:SUPREME HOME CARE AND REHAB INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NASEEM
Authorized Official - Middle Name:AHMED
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-214-1234
Mailing Address - Street 1:29930 W 12 MILE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3983
Mailing Address - Country:US
Mailing Address - Phone:248-862-2512
Mailing Address - Fax:248-862-2145
Practice Address - Street 1:29930 W 12 MILE RD STE 3
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3983
Practice Address - Country:US
Practice Address - Phone:248-862-2512
Practice Address - Fax:248-862-2145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2022-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI638089251E00000X
MI4105160001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E828OtherBCBS OF MICHIGAN
MI2039402Medicaid
MI237609Medicare Oscar/Certification
MI4105160001Medicare NSC