Provider Demographics
NPI:1639904428
Name:SUPRA CARES INC
Entity type:Organization
Organization Name:SUPRA CARES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUJAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GAUTAM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:318-243-5254
Mailing Address - Street 1:6224 N ARLINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-4276
Mailing Address - Country:US
Mailing Address - Phone:318-243-5254
Mailing Address - Fax:
Practice Address - Street 1:3980 SAN PABLO DAM RD STE 101
Practice Address - Street 2:
Practice Address - City:EL SOBRANTE
Practice Address - State:CA
Practice Address - Zip Code:94803-2816
Practice Address - Country:US
Practice Address - Phone:510-775-5670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health