1295784668 NPI number — CRESTVIEW PHYSICAL THERAPY INC

Table of content: (NPI 1295784668)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295784668 NPI number — CRESTVIEW PHYSICAL THERAPY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRESTVIEW PHYSICAL THERAPY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295784668
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2010
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRESTVIEW
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32536-8010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-682-7466
Provider Business Mailing Address Fax Number:
850-682-6591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
577 BROOKMEADE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESTVIEW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32539-6029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-682-7466
Provider Business Practice Location Address Fax Number:
850-682-6591
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
850-682-7466

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT0002988 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT2988 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225200000X , with the licence number: PTA18906 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 887782301 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: Y902Q . This is a "BCBS GRP NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 422880208 . This is a "TRICARE - INDIVIDUAL NUMB" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 650024403 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PTA18906 . This is a "PHYSICAL THERAPIST ASSIST" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 887782300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: PT0002988 . This is a "COMMERCIAL INS NUMBERS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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