Healthcare Provider Details

I. General information

NPI: 1770161390
Provider Name (Legal Business Name): FRESENIUS VASCULAR CARE CRESTVIEW ASC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 COVELL RD
CRESTVIEW FL
32539-6060
US

IV. Provider business mailing address

214 COVELL RD
CRESTVIEW FL
32539-6060
US

V. Phone/Fax

Practice location:
  • Phone: 850-864-4005
  • Fax:
Mailing address:
  • Phone: 850-864-4005
  • Fax: 484-924-0053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GREGG MILLER
Title or Position: SR. VICE PRESIDENT
Credential: MD
Phone: 610-644-8900