Healthcare Provider Details

I. General information

NPI: 1598966343
Provider Name (Legal Business Name): CRESTVIEW HOSPITAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 03/18/2022
Certification Date: 02/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 REDSTONE AVE W
CRESTVIEW FL
32536-8467
US

IV. Provider business mailing address

PO BOX 198002
ATLANTA GA
30384-8002
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number4298
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number4298
License Number StateFL

VIII. Authorized Official

Name: JENNIFER L JACKSON
Title or Position: SR DIR ONBOARDING & PROV ENROLLMENT
Credential:
Phone: 615-465-3334