Provider Demographics
NPI:1891784344
Name:PHC-CRESTVIEW INC
Entity Type:Organization
Organization Name:PHC-CRESTVIEW INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CHIEF OPERATING OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:ATES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:850-682-5322
Mailing Address - Street 1:909 GARDEN GATE CIR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-8629
Mailing Address - Country:US
Mailing Address - Phone:850-479-1012
Mailing Address - Fax:850-479-1013
Practice Address - Street 1:1849 E FIRST AVE
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-3109
Practice Address - Country:US
Practice Address - Phone:850-682-5322
Practice Address - Fax:850-682-5489
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHC-CRESTVIEW INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-18
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1110096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025110100Medicaid
FL025110100Medicaid
FL4356130001Medicare NSC