Healthcare Provider Details

I. General information

NPI: 1578863726
Provider Name (Legal Business Name): CRESTVIEW OPEN MRI INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 E REDSTONE AVE SUITE A
CRESTVIEW FL
32539-5348
US

IV. Provider business mailing address

PO BOX 23697
JACKSON MS
39225-3697
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-6705
  • Fax: 850-689-6709
Mailing address:
  • Phone: 850-689-6705
  • Fax: 850-689-6709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN TOMBERLIN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 334-684-7156