Provider Demographics
NPI:1215568985
Name:IMPERIAL LIVNG INC
Entity Type:Organization
Organization Name:IMPERIAL LIVNG INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MS
Authorized Official - First Name:NISA
Authorized Official - Middle Name:N
Authorized Official - Last Name:CARABALLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-512-8465
Mailing Address - Street 1:2820 39TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33714-4524
Mailing Address - Country:US
Mailing Address - Phone:727-657-5767
Mailing Address - Fax:
Practice Address - Street 1:2820 39TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33714-4524
Practice Address - Country:US
Practice Address - Phone:727-657-5767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100285000Medicaid