Provider Demographics
NPI:1891294153
Name:SUPREME HOME LLC
Entity Type:Organization
Organization Name:SUPREME HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AJOKE
Authorized Official - Middle Name:OLOHIMA
Authorized Official - Last Name:KOLAWOLE
Authorized Official - Suffix:
Authorized Official - Credentials:BA, CNA
Authorized Official - Phone:907-830-6959
Mailing Address - Street 1:2600 A BRYANT CIRCLE
Mailing Address - Street 2:P.O BOX 142764
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99514-2764
Mailing Address - Country:US
Mailing Address - Phone:907-929-1141
Mailing Address - Fax:907-868-4670
Practice Address - Street 1:2600A BRYANT CIR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-3252
Practice Address - Country:US
Practice Address - Phone:907-929-1141
Practice Address - Fax:907-868-4670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-01
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1030505Medicaid