- Enrollment id
- O20210923000557
- Enrollment state
- CA
- Provider type code
- 00-06
- Provider type text
- PART A PROVIDER - HOME HEALTH AGENCY
- Npi
- 1275008443
- Multiple npi flag
- N
- Ccn
- 753115
- Associate id
- 5597162214
- Organization name
- SUPREME CARE GROUP
- Incorporation date
- 2018-05-23
- Incorporation state
- CA
- Organization type structure
- CORPORATION
- Proprietary nonprofit
- P
- Address line 1
- 6005 VINELAND AVE
- Address line 2
- STE 211
- City
- NORTH HOLLYWOOD
- State
- CA
- Zip code
- 916064982