Healthcare Provider Details

I. General information

NPI: 1801608005
Provider Name (Legal Business Name): BLAQ PEARL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2025
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14926 FISHER RD
TAMPA FL
33613-1609
US

IV. Provider business mailing address

30203 GOODWICK WAY
WESLEY CHAPEL FL
33543-3961
US

V. Phone/Fax

Practice location:
  • Phone: 813-448-2235
  • Fax:
Mailing address:
  • Phone: 813-210-5535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name: PEARL T WILLIAMS-SYLVAIN
Title or Position: MANAGER
Credential:
Phone: 813-210-5535