Provider Demographics
NPI:1144458647
Name:CRESTVIEW URGENT CARE, INC.
Entity type:Organization
Organization Name:CRESTVIEW URGENT CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:CLANCY
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:850-398-8668
Mailing Address - Street 1:1502 S FERDON BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-8444
Mailing Address - Country:US
Mailing Address - Phone:850-398-8668
Mailing Address - Fax:
Practice Address - Street 1:1502 S FERDON BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-8444
Practice Address - Country:US
Practice Address - Phone:850-398-1079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-23
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93880261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH36106Medicare UPIN