Provider Demographics
NPI:1679347637
Name:SUPREME LEADERSHIP LLC
Entity Type:Organization
Organization Name:SUPREME LEADERSHIP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FRANCHISE OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:REY
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:407-350-7084
Mailing Address - Street 1:2222 VAN BUREN ST APT 14
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-5176
Mailing Address - Country:US
Mailing Address - Phone:407-350-7084
Mailing Address - Fax:
Practice Address - Street 1:2875 NE 191ST ST OFC 540
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33180-2801
Practice Address - Country:US
Practice Address - Phone:786-733-3576
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care