Provider Demographics
NPI:1215621081
Name:SUPREME RECUPERATIVE CARE
Entity type:Organization
Organization Name:SUPREME RECUPERATIVE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GEVORG
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIGORYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-322-0098
Mailing Address - Street 1:10462 YARMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-5932
Mailing Address - Country:US
Mailing Address - Phone:818-322-0098
Mailing Address - Fax:818-322-0089
Practice Address - Street 1:10462 YARMOUTH AVE
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-5932
Practice Address - Country:US
Practice Address - Phone:818-322-0098
Practice Address - Fax:818-322-0089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-05
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care