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General NPI Number Information
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NPI Number | 1891850855
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Entity Type | Organization
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Legal Business Name | CRESTVIEW PEDIATRICS AND ADOLESCENT CENTER PA
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Dates
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Enumeration Date | 12/27/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 332 MEDCREST DRIVE
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City | CRESTVIEW
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State | FL
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Zip | 32536
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Country | US
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Telephone | 850-683-5100
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Fax | 850-683-5102
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Provider Business Mailing Address
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Address Line | 332 MEDCREST DRIVE
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City | CRESTVIEW
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State | FL
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Zip | 32536
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Country | US
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Telephone | 850-683-5100
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Fax | 850-683-5102
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Authorized Official
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Title or Position | OFFICE MGR
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Name | MRS. BERNADINE S PETER
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Credential |
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Telephone | 850-683-5100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | ME74916
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License Number State | FL
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