MEDICARE: IMAGINARY RAINBOW LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1235697434
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMAGINARY RAINBOW LLC

Provider Business Mailing Address
First Line	:	407 WEKIVA SPRINGS RD STE 207-I
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32779-6096
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	407 WEKIVA SPRINGS RD STE 207-I
Second Line	:
City	:	LONGWOOD
State	:	FL
Zip	:	32779-6096
Country	:	US
Telephone Number	:	786-452-3145
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ZAHILY MESA ROMAN
Credential	:
Telephone Number	:	786-452-3145

Provider Enumeration Date	:	03/06/2019
Last Update Date	:	03/08/2019

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