Healthcare Provider Details

I. General information

NPI: 1033929641
Provider Name (Legal Business Name): PROMINENCES KINDRED CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 W ARCH ST STE A
TAMPA FL
33607-5516
US

IV. Provider business mailing address

1508 W ARCH ST STE A
TAMPA FL
33607-5516
US

V. Phone/Fax

Practice location:
  • Phone: 717-678-6321
  • Fax: 850-260-0842
Mailing address:
  • Phone: 717-678-6321
  • Fax: 850-260-0842

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 Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: MR. FREDDIE LEE FAGAN JR.
Title or Position: MR.
Credential:
Phone: 717-678-6321