Provider Demographics
NPI:1740871763
Name:SUPPORTIVE CARE LLC
Entity type:Organization
Organization Name:SUPPORTIVE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:WATTERS
Authorized Official - Suffix:
Authorized Official - Credentials:PRACTICAL NURSE
Authorized Official - Phone:586-252-6974
Mailing Address - Street 1:14823 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-4004
Mailing Address - Country:US
Mailing Address - Phone:586-252-6974
Mailing Address - Fax:
Practice Address - Street 1:14823 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-4004
Practice Address - Country:US
Practice Address - Phone:586-252-6974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty