Provider Demographics
NPI:1922209162
Name:SUPRA HOME HEALTH, INC.
Entity Type:Organization
Organization Name:SUPRA HOME HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIETO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-443-6461
Mailing Address - Street 1:6720 TAFT ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-3903
Mailing Address - Country:US
Mailing Address - Phone:954-443-6461
Mailing Address - Fax:954-443-6462
Practice Address - Street 1:6720 TAFT ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-3903
Practice Address - Country:US
Practice Address - Phone:954-443-6461
Practice Address - Fax:954-443-6462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL299992774251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL651652100Medicaid
FL299992774OtherLICENSE
FL651652100Medicaid