| Entity Name: | CRESTVIEW REHABILITATION CENTER, LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Foreign Limited Liability Company |
| Status: | Active |
| Date Filed: | 28 Oct 2011 (13 years ago) |
| Document Number: | M11000005434 |
| FEI/EIN Number | 30-0702809 |
| Mail Address: | 101 Sunnytown Road, Suite 201, Casselberry, FL 32707 |
| Address: | 1849 First Avenue East, Crestview, FL 32539 |
| ZIP code: | 32539 |
| County: | Okaloosa |
| Place of Formation: | DELAWARE |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1821374505 | 2011-10-26 | 2014-09-29 | 5887 GLENRIDGE DR NE, SUITE 150, ATLANTA, GA, 303285574, US | 1849 E FIRST AVE, CRESTVIEW, FL, 325393109, US | |||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||
| Phone | +1 404-574-2100 |
| Fax | 4045742105 |
| Phone | +1 850-682-5322 |
| Fax | 8506825489 |
Authorized person
| Name | MR. R. MARK CRONQUIST |
| Role | MANAGER |
| Phone | 4045742100 |
Taxonomy
| Taxonomy Code | 314000000X - Skilled Nursing Facility |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 314000000X - Skilled Nursing Facility |
| License Number | SNF1110096 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 004488600 |
| State | FL |
| Name | Role |
|---|---|
| COGENCY GLOBAL INC. | Agent |
| Name | Role |
|---|---|
| SOUTHERN HEALTHCARE MANAGEMENT, LLC | MANAGER |
| Name | Role |
|---|---|
| SOUTHERN HEALTHCARE MANAGEMENT, LLC | manager |
| Name | Role |
|---|---|
| SOUTHERN HEALTHCARE MANAGEMENT, LLC | managed) |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2017-03-30 | 1849 First Avenue East, Crestview, FL 32539 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2015-07-07 | 115 North Calhoun St., Suite 4, Tallahassee, FL 32301 | No data |
| CHANGE OF MAILING ADDRESS | 2014-01-10 | 1849 First Avenue East, Crestview, FL 32539 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-05 |
| ANNUAL REPORT | 2023-03-09 |
| ANNUAL REPORT | 2022-02-24 |
| ANNUAL REPORT | 2021-03-18 |
| ANNUAL REPORT | 2020-04-14 |
| ANNUAL REPORT | 2019-03-21 |
| ANNUAL REPORT | 2018-04-27 |
| ANNUAL REPORT | 2017-03-30 |
| ANNUAL REPORT | 2016-03-30 |
| ANNUAL REPORT | 2015-01-12 |
Date of last update: 24 Jan 2025
Sources: Florida Department of State
