Provider Demographics
NPI:1982175154
Name:SUPREME NURSING CARE AND SUPPORTED LIVING LLC
Entity Type:Organization
Organization Name:SUPREME NURSING CARE AND SUPPORTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
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:MPH
Authorized Official - Phone:614-929-1931
Mailing Address - Street 1:1101 W HAMILTON ST STE 141
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18101-1043
Mailing Address - Country:US
Mailing Address - Phone:614-929-1931
Mailing Address - Fax:
Practice Address - Street 1:1101 W HAMILTON ST STE 141
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18101-1043
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:2018-12-16
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1035115810001Medicaid