Provider Demographics
NPI:1659348712
Name:CRESTVIEW HOSPITAL COMPANY, LLC
Entity Type:Organization
Organization Name:CRESTVIEW HOSPITAL COMPANY, LLC
Other - Org Name:GATEWAY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:LALOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-215-3953
Mailing Address - Street 1:PO BOX 198002
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:127 E REDSTONE AVE
Practice Address - Street 2:STE C
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-5358
Practice Address - Country:US
Practice Address - Phone:850-423-0061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRESTVIEW HOSPITAL COMPANY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-07
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC3810261QR1300X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103999Medicare Oscar/Certification