Provider Demographics
NPI:1972591311
Name:SUPPLEMENTAL PROFESSIONAL RESOURCES, INC.
Entity Type:Organization
Organization Name:SUPPLEMENTAL PROFESSIONAL RESOURCES, INC.
Other - Org Name:NIAGARA HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:KEPNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-514-5527
Mailing Address - Street 1:3976 LOCKPORT OLCOTT RD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-1133
Mailing Address - Country:US
Mailing Address - Phone:716-433-7810
Mailing Address - Fax:716-433-7811
Practice Address - Street 1:3976 LOCKPORT OLCOTT RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-1133
Practice Address - Country:US
Practice Address - Phone:716-433-7810
Practice Address - Fax:716-433-7811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9969L001251E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251E00000XAgenciesHome Health
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01879616Medicaid
NY8210096OtherIHA BILLING #
NY00011340201OtherUNIVERA BILLING #
NY000551258001OtherBCBS BILLING #
NY01779735Medicaid
NY01879616Medicaid