Provider Demographics
NPI:1891009007
Name:SUPREME CHOICE MED CARE, LLC
Entity type:Organization
Organization Name:SUPREME CHOICE MED CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:281-988-7300
Mailing Address - Street 1:1922 BROWN SCHOOL CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77406-6727
Mailing Address - Country:US
Mailing Address - Phone:281-988-7300
Mailing Address - Fax:281-988-7302
Practice Address - Street 1:5002 S LAKE HOUSTON PKWY
Practice Address - Street 2:SUITE 7
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77049-2630
Practice Address - Country:US
Practice Address - Phone:281-988-7300
Practice Address - Fax:281-988-7302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-29
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX673649261QH0100X
363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service