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General NPI Number Information
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NPI Number | 1073134730
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Entity Type | Organization
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Legal Business Name | CRESTVIEW IMMEDIATE CARE LLC
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Dates
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Enumeration Date | 05/04/2020
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Last Update Date | 06/09/2020
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Provider Practice Location Address
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Address Line | 4100 S FERDON BLVD STE A3
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City | CRESTVIEW
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State | FL
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Zip | 32536-5287
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Country | US
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Telephone | 850-758-7791
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Fax |
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Provider Business Mailing Address
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Address Line | 4100 S FERDON BLVD STE A3
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City | CRESTVIEW
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State | FL
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Zip | 32536-5287
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Country | US
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Telephone | 850-634-6345
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Fax | 850-634-6345
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Authorized Official
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Title or Position | OWNER
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Name | ALIASON HEATHER MARTIN-OVERTON
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Credential | ARNP
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Telephone | 850-634-6345
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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