1871901322 NPI number — SUPREME HEALTHCARE SUPPLY LLC

Table of content: (NPI 1871901322)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871901322 NPI number — SUPREME HEALTHCARE SUPPLY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPREME HEALTHCARE SUPPLY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871901322
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1035 NE 125TH ST
Provider Second Line Business Mailing Address:
301
Provider Business Mailing Address City Name:
NORTH MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33161-5820
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-859-3350
Provider Business Mailing Address Fax Number:
305-928-2535

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1035 NE 125TH ST
Provider Second Line Business Practice Location Address:
301
Provider Business Practice Location Address City Name:
NORTH MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33161-5820
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-859-3350
Provider Business Practice Location Address Fax Number:
305-928-2535
Provider Enumeration Date:
07/29/2014

Additional Information

Authorized Official

Authorized Official Last Name:
RUIZ-OTERO
Authorized Official First Name:
IVAN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
305-859-3350

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X , with the licence number:  PED218 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7544650001 . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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