Provider Demographics
NPI:1073569166
Name:CRESTVIEW OPEN MRI INC
Entity Type:Organization
Organization Name:CRESTVIEW OPEN MRI INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:CADENHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-869-6705
Mailing Address - Street 1:194 E REDSTONE AVE
Mailing Address - Street 2:STE. A
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-5348
Mailing Address - Country:US
Mailing Address - Phone:850-689-6705
Mailing Address - Fax:
Practice Address - Street 1:194 E REDSTONE AVE
Practice Address - Street 2:STE. A
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-5348
Practice Address - Country:US
Practice Address - Phone:850-689-6705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL000439261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU0989Medicare ID - Type UnspecifiedIDTF NUMBER