Healthcare Provider Details

I. General information

NPI: 1225847833
Provider Name (Legal Business Name): CREST CUSTOM MOBILITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2025
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 MOUNTAIN DR STE I
DESTIN FL
32541-7334
US

IV. Provider business mailing address

4533 LEILANI LN
MERRITT ISLAND FL
32953-8500
US

V. Phone/Fax

Practice location:
  • Phone: 321-360-6016
  • Fax:
Mailing address:
  • Phone: 321-360-6016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: LINDSAY SEGO
Title or Position: CEO
Credential:
Phone: 321-360-6016