Healthcare Provider Details

I. General information

NPI: 1215568985
Provider Name (Legal Business Name): IMPERIAL LIVNG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 39TH AVE N
ST PETERSBURG FL
33714-4524
US

IV. Provider business mailing address

2820 39TH AVE N
ST PETERSBURG FL
33714-4524
US

V. Phone/Fax

Practice location:
  • Phone: 727-657-5767
  • Fax:
Mailing address:
  • Phone: 727-657-5767
  • Fax:

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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. NISA N CARABALLO
Title or Position: COO
Credential:
Phone: 727-512-8465