# SUPREME INDEPENDENCE ROOM AND BOARD

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1972267870
- **Authorized official:** MR. JAMES BLAKE (OWNER)
- **Authorized official phone:** (810) 660-1892

## Contact information

- **Practice address:** 12844 BROADSTREET AVE, DETROIT, MI 48238-3250
- **Practice address phone:** (313) 459-9538
- **Mailing address:** 36306 DOMINION CIR, STERLING HEIGHTS, MI 48310-7458
- **Mailing address phone:** (810) 660-1892

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 177F00000X | Lodging Provider | — | — | Yes |

## Other

- **Enumeration date:** 10/26/2021
- **Last updated:** 10/26/2021