Provider Demographics
NPI:1730759168
Name:SUPREME HABILITATIVE SERVICES LLC
Entity type:Organization
Organization Name:SUPREME HABILITATIVE SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:RACKAYE
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-751-8330
Mailing Address - Street 1:100 S ASHLEY DR STE 600
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5300
Mailing Address - Country:US
Mailing Address - Phone:866-751-8330
Mailing Address - Fax:813-922-0553
Practice Address - Street 1:100 S ASHLEY DR STE 600
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-5300
Practice Address - Country:US
Practice Address - Phone:813-381-0595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-28
Last Update Date:2021-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral DisturbancesGroup - Single Specialty
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL01Medicaid