Healthcare Provider Details

I. General information

NPI: 1811612674
Provider Name (Legal Business Name): CLEMONS GROUP HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 CLEMONS RD
PLANT CITY FL
33566-4643
US

IV. Provider business mailing address

3111 CLEMONS RD
PLANT CITY FL
33566-4643
US

V. Phone/Fax

Practice location:
  • Phone: 813-810-6844
  • Fax: 813-602-2388
Mailing address:
  • Phone: 813-810-6844
  • Fax: 813-602-2388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CASSANDRA VIRGINIA SIMPSON
Title or Position: ADMINISTRATOR
Credential: BSN, RN
Phone: 813-810-6844