Provider Demographics
NPI:1184112427
Name:IMPERIAL CONNECTIONS SUPPORT PROGRAMS, LLC
Entity type:Organization
Organization Name:IMPERIAL CONNECTIONS SUPPORT PROGRAMS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMERLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:EDS
Authorized Official - Phone:813-395-9950
Mailing Address - Street 1:5450 BRUCE B DOWNS BLVD STE 328
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-8616
Mailing Address - Country:US
Mailing Address - Phone:813-395-9950
Mailing Address - Fax:813-364-6474
Practice Address - Street 1:9806 N CONNECHUSETT RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617
Practice Address - Country:US
Practice Address - Phone:813-395-9950
Practice Address - Fax:813-364-6474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-23
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL022101700253Z00000X, 320900000X, 385HR2060X
FL235233251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022101700Medicaid