Provider Demographics
NPI:1295951473
Name:SUPREME HOME CARE, INC
Entity type:Organization
Organization Name:SUPREME HOME CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-454-0155
Mailing Address - Street 1:1204 E BASELINE RD STE 204
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1453
Mailing Address - Country:US
Mailing Address - Phone:602-454-0155
Mailing Address - Fax:602-454-0156
Practice Address - Street 1:1204 E BASELINE RD STE 204
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1453
Practice Address - Country:US
Practice Address - Phone:602-454-0155
Practice Address - Fax:602-454-0156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHHA3554251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ927577Medicaid
AZ037231Medicare ID - Type UnspecifiedMEDICARE NUMBER