Provider Demographics
NPI:1902145766
Name:SUPPLEMENTAL HEALTHCARE
Entity Type:Organization
Organization Name:SUPPLEMENTAL HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPY ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-567-9881
Mailing Address - Street 1:4720 E COTTON GIN LOOP
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85040-4823
Mailing Address - Country:US
Mailing Address - Phone:602-567-9881
Mailing Address - Fax:
Practice Address - Street 1:4720 E COTTON GIN LOOP
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-4823
Practice Address - Country:US
Practice Address - Phone:602-567-9881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4186283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital