Provider Demographics
NPI:1639661317
Name:SUPREME HEALTHCARE AGENCY LLC
Entity Type:Organization
Organization Name:SUPREME HEALTHCARE AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CAMPBELL-RASBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:440-521-2276
Mailing Address - Street 1:38335 TAMARAC BLVD APT 220
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-8195
Mailing Address - Country:US
Mailing Address - Phone:440-521-2276
Mailing Address - Fax:
Practice Address - Street 1:38335 TAMARAC BLVD APT 220
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-8195
Practice Address - Country:US
Practice Address - Phone:440-521-2276
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services