Healthcare Provider Details

I. General information

NPI: 1831972462
Provider Name (Legal Business Name): SUPPORT360 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 17TH AVE S
SAINT PETERSBURG FL
33712-2742
US

IV. Provider business mailing address

2200 17TH AVE S
SAINT PETERSBURG FL
33712-2742
US

V. Phone/Fax

Practice location:
  • Phone: 727-564-3556
  • Fax:
Mailing address:
  • Phone: 727-564-3556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KEIONDE K THOMPSON
Title or Position: OWNER
Credential:
Phone: 727-564-3556