Provider Demographics
NPI:1093017642
Name:CUSTOM HEALTHCARE, LLC
Entity type:Organization
Organization Name:CUSTOM HEALTHCARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-697-0057
Mailing Address - Street 1:3700 BRAINERD RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-3603
Mailing Address - Country:US
Mailing Address - Phone:423-697-0057
Mailing Address - Fax:423-648-9366
Practice Address - Street 1:1508 N THORNTON AVE
Practice Address - Street 2:STE 104
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-8516
Practice Address - Country:US
Practice Address - Phone:706-529-7651
Practice Address - Fax:706-529-7680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier