Provider Demographics
NPI:1073134730
Name:CRESTVIEW IMMEDIATE CARE LLC
Entity Type:Organization
Organization Name:CRESTVIEW IMMEDIATE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALIASON
Authorized Official - Middle Name:HEATHER
Authorized Official - Last Name:MARTIN-OVERTON
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:850-634-6345
Mailing Address - Street 1:4100 S FERDON BLVD STE A3
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-5287
Mailing Address - Country:US
Mailing Address - Phone:850-634-6345
Mailing Address - Fax:850-634-6345
Practice Address - Street 1:4100 S FERDON BLVD STE A3
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-5287
Practice Address - Country:US
Practice Address - Phone:850-758-7791
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-04
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care