Provider Demographics
NPI:1831625037
Name:SUPPLEMENTAL HEALTHCARE
Entity type:Organization
Organization Name:SUPPLEMENTAL HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECRUITING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERRELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:984-444-9903
Mailing Address - Street 1:319 VANCOUVER DR
Mailing Address - Street 2:APARTMENT 38G
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5785
Mailing Address - Country:US
Mailing Address - Phone:347-447-1868
Mailing Address - Fax:
Practice Address - Street 1:319 VANCOUVER DRIVE
Practice Address - Street 2:APARTMENT 38G
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303
Practice Address - Country:US
Practice Address - Phone:347-447-1868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-08
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1Medicaid