Provider Demographics
NPI:1871901322
Name:SUPREME HEALTHCARE SUPPLY LLC
Entity type:Organization
Organization Name:SUPREME HEALTHCARE SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:RUIZ-OTERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-859-3350
Mailing Address - Street 1:1035 NE 125TH ST
Mailing Address - Street 2:301
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-5820
Mailing Address - Country:US
Mailing Address - Phone:305-859-3350
Mailing Address - Fax:305-928-2535
Practice Address - Street 1:1035 NE 125TH ST
Practice Address - Street 2:301
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-5820
Practice Address - Country:US
Practice Address - Phone:305-859-3350
Practice Address - Fax:305-928-2535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-29
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPED218332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7544650001OtherMEDICARE PTAN