Healthcare Provider Details

I. General information

NPI: 1063326965
Provider Name (Legal Business Name): CRESTVIEW HOSPITAL COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 REDSTONE AVE W
CRESTVIEW FL
32536-8467
US

IV. Provider business mailing address

151 E REDSTONE AVE
CRESTVIEW FL
32539-5352
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-8100
  • Fax: 850-689-8488
Mailing address:
  • Phone: 850-689-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: PAULA LALOR
Title or Position: SR DIRECTOR
Credential:
Phone: 629-215-3953