Provider Demographics
NPI:1639552649
Name:SUPREME HEALTHCARE OB/GYN LLC
Entity Type:Organization
Organization Name:SUPREME HEALTHCARE OB/GYN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-518-9691
Mailing Address - Street 1:5536 FLAT SHOALS PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-5408
Mailing Address - Country:US
Mailing Address - Phone:678-518-9691
Mailing Address - Fax:678-518-9692
Practice Address - Street 1:5536 FLAT SHOALS PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-5408
Practice Address - Country:US
Practice Address - Phone:678-518-9691
Practice Address - Fax:678-518-9692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA57621174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty