1821374505 NPI number — CRESTVIEW REHABILITATION CENTER, LLC

Table of content: (NPI 1821374505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821374505 NPI number — CRESTVIEW REHABILITATION CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRESTVIEW REHABILITATION CENTER, LLC
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:
1821374505
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5887 GLENRIDGE DR NE
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30328-5574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-574-2100
Provider Business Mailing Address Fax Number:
404-574-2105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1849 E FIRST AVE
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:
32539-3109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-682-5322
Provider Business Practice Location Address Fax Number:
850-682-5489
Provider Enumeration Date:
10/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CRONQUIST
Authorized Official First Name:
R.
Authorized Official Middle Name:
MARK
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
404-574-2100

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: SNF1110096 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004488600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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