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General NPI Number Information
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NPI Number | 1184112427
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Entity Type | Organization
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Legal Business Name | IMPERIAL CONNECTIONS SUPPORT PROGRAMS, LLC
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Dates
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Enumeration Date | 04/23/2018
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Last Update Date | 05/30/2018
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Provider Practice Location Address
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Address Line | 9806 N CONNECHUSETT RD
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City | TAMPA
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State | FL
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Zip | 33617
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Country | US
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Telephone | 813-395-9950
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Fax | 813-364-6474
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Provider Business Mailing Address
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Address Line | 5450 BRUCE B DOWNS BLVD STE 328
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City | WESLEY CHAPEL
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State | FL
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Zip | 33544-8616
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Country | US
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Telephone | 813-395-9950
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Fax | 813-364-6474
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Authorized Official
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Title or Position | OWNER
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Name | KIMERLYN JOHNSON
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Credential | ED.S.
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Telephone | 813-395-9950
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | 022101700
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 022101700
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 385HR2060X
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Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
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License Number | 022101700
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 235233
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License Number State | FL
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