| Entity Name: | CRESTVIEW PHYSICAL THERAPY INC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 04 Jan 1995 (30 years ago) |
| Document Number: | P95000001360 |
| FEI/EIN Number | 593291910 |
| Address: | 577 BROOKMEADE DR, CRESTVIEW, FL, 32539, US |
| Mail Address: | P O BOX 2010, CRESTVIEW, FL, 32536, US |
| ZIP code: | 32539 |
| County: | Okaloosa |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1295784668 | 2006-05-10 | 2022-11-22 | PO BOX 2010, CRESTVIEW, FL, 325368010, US | 577 BROOKMEADE DR, CRESTVIEW, FL, 325396029, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 850-682-7466 |
| Fax | 8506826591 |
Authorized person
| Name | THOMAS A. MILLER |
| Role | PRESIDENT |
| Phone | 8506827466 |
Taxonomy
| Taxonomy Code | 225100000X - Physical Therapist |
| License Number | PT0002988 |
| State | FL |
| Is Primary | No |
| Taxonomy Code | 225100000X - Physical Therapist |
| License Number | PT2988 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 225200000X - Physical Therapy Assistant |
| License Number | PTA18906 |
| State | FL |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 887782301 |
| State | FL |
| Issuer | BCBS GRP NUMBER |
| Number | Y902Q |
| State | FL |
| Issuer | TRICARE - INDIVIDUAL NUMB |
| Number | 422880208 |
| State | FL |
| Issuer | RAILROAD MEDICARE |
| Number | 650024403 |
| State | FL |
| Issuer | PHYSICAL THERAPIST ASSIST |
| Number | PTA18906 |
| State | FL |
| Issuer | MEDICAID |
| Number | 887782300 |
| State | FL |
| Issuer | COMMERCIAL INS NUMBERS |
| Number | PT0002988 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| MILLER THOMAS A | Agent | 577 BROOKMEADE DRIVE, CRESTVIEW, FL, 32539 |
| Name | Role | Address |
|---|---|---|
| MILLER THOMAS A | President | 105 woodland Dr., CRESTVIEW, FL, 32539 |
| Name | Role | Address |
|---|---|---|
| MILLER THOMAS A | Vice President | 105 woodland Dr., CRESTVIEW, FL, 32539 |
| Name | Role | Address |
|---|---|---|
| MILLER THOMAS A | Secretary | 105 woodland Dr., CRESTVIEW, FL, 32539 |
| Name | Role | Address |
|---|---|---|
| MILLER THOMAS A | Treasurer | 105 woodland Dr., CRESTVIEW, FL, 32539 |
| Name | Role | Address |
|---|---|---|
| MILLER THOMAS A | Director | 105 Woodland Dr, CRESTVIEW, FL, 32539 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G09000182374 | CRESTVIEW PHYSICAL THERAPY CLINIC | EXPIRED | 2009-12-08 | 2024-12-31 | No data | PO BOX 2010, CRESTVIEW, FL, 32536 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| NAME CHANGE AMENDMENT | 2012-07-09 | CRESTVIEW PHYSICAL THERAPY INC | No data |
| REINSTATEMENT | 2005-10-07 | No data | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2005-09-16 | No data | No data |
Date of last update: 01 Jan 2025
Sources: Florida Department of State
