Provider Demographics
NPI:1871864124
Name:SUPREME HEALTHCARE SERVICES, LLC
Entity Type:Organization
Organization Name:SUPREME HEALTHCARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:GANIYAT
Authorized Official - Middle Name:FUNMI
Authorized Official - Last Name:EFUNTOYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-357-8763
Mailing Address - Street 1:6475 NEW HAMPSHIRE AVE
Mailing Address - Street 2:SUITE 315
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20783-3282
Mailing Address - Country:US
Mailing Address - Phone:240-357-8763
Mailing Address - Fax:240-863-3313
Practice Address - Street 1:4611 CLAY ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-4663
Practice Address - Country:US
Practice Address - Phone:240-357-8763
Practice Address - Fax:240-863-3313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC057293200Medicaid