Supreme Nursing Care and Supported Living LLC

Primary specialty

Home Health AgencyTaxonomy code 251E00000X

Legal business name

SUPREME NURSING CARE AND SUPPORTED LIVING LLC

Practice address

1401 Marlton Pike E Ste 22a
Cherry Hill, NJ 08034-2207

Phone

(614) 929-1931

NPI assigned

Dec 16, 2018

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Mohamed Baba Fofanah, MPH

Title

Ceo

Phone

(614) 929-1931

Specialties & licenses 3

Addresses

Other identifiers 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1544918400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1738713600000",
    "number": "1982175154",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1101 W HAMILTON ST STE 141",
            "city": "ALLENTOWN",
            "state": "PA",
            "postal_code": "181011043",
            "telephone_number": "614-929-1931"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1401 MARLTON PIKE E STE 22A",
            "city": "CHERRY HILL",
            "state": "NJ",
            "postal_code": "080342207",
            "telephone_number": "614-929-1931"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1101 W Hamilton St Ste 141",
            "address_purpose": "LOCATION",
            "city": "Allentown",
            "state": "PA",
            "postal_code": "181011043",
            "country_code": "US",
            "telephone_number": "614-929-1931",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "SUPREME NURSING CARE AND SUPPORTED LIVING LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-12-16",
        "last_updated": "2025-02-05",
        "certification_date": "2025-02-05",
        "status": "A",
        "authorized_official_last_name": "FOFANAH",
        "authorized_official_first_name": "MOHAMED",
        "authorized_official_middle_name": "BABA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "614-929-1931",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MPH"
    },
    "taxonomies": [
        {
            "code": "251E00000X",
            "taxonomy_group": "",
            "desc": "Home Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "320900000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "343900000X",
            "taxonomy_group": "",
            "desc": "Non-emergency Medical Transport (VAN)",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1035115810001",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 5, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.