Healthcare Provider Details

I. General information

NPI: 1629026133
Provider Name (Legal Business Name): CRESTVIEW HOSPITAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 03/18/2022
Certification Date: 02/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127C E. REDSTONE AVE
CRESTVIEW FL
32539-5356
US

IV. Provider business mailing address

330 FRANKLIN RD # 135A-316
BRENTWOOD TN
37027-3280
US

V. Phone/Fax

Practice location:
  • Phone: 850-423-0061
  • Fax:
Mailing address:
  • Phone: 615-465-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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