Provider Demographics
NPI:1205331915
Name:SUPREME CARE
Entity type:Organization
Organization Name:SUPREME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:BABA
Authorized Official - Last Name:FOFANAH
Authorized Official - Suffix:
Authorized Official - Credentials:ASP, OHST
Authorized Official - Phone:614-929-1931
Mailing Address - Street 1:449 WILLOW ST APT J
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18102-5765
Mailing Address - Country:US
Mailing Address - Phone:614-929-1931
Mailing Address - Fax:
Practice Address - Street 1:4920 NIAGARA RD STE 406
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-1166
Practice Address - Country:US
Practice Address - Phone:614-929-1931
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty