Provider Demographics
NPI:1891922217
Name:SUPREME LOVE
Entity Type:Organization
Organization Name:SUPREME LOVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:FORSYTHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-234-6163
Mailing Address - Street 1:4232 COGHILL DR N
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27896-9503
Mailing Address - Country:US
Mailing Address - Phone:252-234-6163
Mailing Address - Fax:252-234-6163
Practice Address - Street 1:4232 COGHILL DR N
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-9503
Practice Address - Country:US
Practice Address - Phone:252-234-6163
Practice Address - Fax:252-234-6163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL098132320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities