1720469893 NPI number — SUPRENE HOME CARE GIVERS AGENCY LLC

Table of content: (NPI 1720469893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720469893 NPI number — SUPRENE HOME CARE GIVERS AGENCY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPRENE HOME CARE GIVERS AGENCY 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:
6
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:
1720469893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
32385 GLEN CV
Provider Second Line Business Mailing Address:
5
Provider Business Mailing Address City Name:
FARMINGTON HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48334-3663
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-782-4814
Provider Business Mailing Address Fax Number:
313-338-8985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3011 W GRAND BLVD
Provider Second Line Business Practice Location Address:
858
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48202-3096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-782-4814
Provider Business Practice Location Address Fax Number:
313-338-8985
Provider Enumeration Date:
06/15/2015

Additional Information

Authorized Official

Authorized Official Last Name:
REED
Authorized Official First Name:
PAMALA
Authorized Official Middle Name:
JOY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
313-989-3576

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  E29729 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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