Provider Demographics
NPI:1285386771
Name:SUPREME DIABETES MANAGEMENT AND WEIGHT LOSS TELEHEALTH
Entity type:Organization
Organization Name:SUPREME DIABETES MANAGEMENT AND WEIGHT LOSS TELEHEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:LEANN
Authorized Official - Last Name:STEPHERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:740-851-1325
Mailing Address - Street 1:920 SALINGER DR
Mailing Address - Street 2:
Mailing Address - City:LITHOPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:43136-7505
Mailing Address - Country:US
Mailing Address - Phone:740-851-1325
Mailing Address - Fax:740-835-4850
Practice Address - Street 1:920 SALINGER DR
Practice Address - Street 2:
Practice Address - City:LITHOPOLIS
Practice Address - State:OH
Practice Address - Zip Code:43136-7505
Practice Address - Country:US
Practice Address - Phone:740-851-1325
Practice Address - Fax:740-835-4850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty