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General NPI Number Information
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NPI Number | 1144458647
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Entity Type | Organization
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Legal Business Name | CRESTVIEW URGENT CARE, INC.
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Dates
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Enumeration Date | 06/23/2009
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Last Update Date | 08/27/2010
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Provider Practice Location Address
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Address Line | 1502 S FERDON BLVD
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City | CRESTVIEW
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State | FL
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Zip | 32536-8444
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Country | US
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Telephone | 850-398-1079
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Fax |
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Provider Business Mailing Address
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Address Line | 1502 S FERDON BLVD
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City | CRESTVIEW
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State | FL
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Zip | 32536-8444
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Country | US
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Telephone | 850-398-8668
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN ASSISTANT
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Name | CHARLES JOSEPH CLANCY
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Credential | PA-C
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Telephone | 850-398-8668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number | ME93880
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License Number State | FL
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