Provider Demographics
NPI:1154604700
Name:SUPPLEMENTAL HEALTHCARE
Entity type:Organization
Organization Name:SUPPLEMENTAL HEALTHCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAISERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:999-999-9999
Mailing Address - Street 1:5135 MARSHALL ISLAND CT
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-0962
Mailing Address - Country:US
Mailing Address - Phone:702-494-9323
Mailing Address - Fax:
Practice Address - Street 1:1120 N TOWN CENTER DR STE 120
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-6302
Practice Address - Country:US
Practice Address - Phone:999-999-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRC1676251J00000X, 283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No283X00000XHospitalsRehabilitation Hospital