Healthcare Provider Details

I. General information

NPI: 1184112427
Provider Name (Legal Business Name): IMPERIAL CONNECTIONS SUPPORT PROGRAMS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 05/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9806 N CONNECHUSETT RD
TAMPA FL
33617
US

IV. Provider business mailing address

5450 BRUCE B DOWNS BLVD STE 328
WESLEY CHAPEL FL
33544-8616
US

V. Phone/Fax

Practice location:
  • Phone: 813-395-9950
  • Fax: 813-364-6474
Mailing address:
  • Phone: 813-395-9950
  • Fax: 813-364-6474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number235233
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number022101700
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number022101700
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number022101700
License Number StateFL

VIII. Authorized Official

Name: KIMERLYN JOHNSON
Title or Position: OWNER
Credential: ED.S.
Phone: 813-395-9950