Provider Demographics
NPI:1154334266
Name:CUSTOM HEALTHCARE OF GEORGIA LLC
Entity type:Organization
Organization Name:CUSTOM HEALTHCARE OF GEORGIA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TAMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:FEITEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-257-3443
Mailing Address - Street 1:2700 LORD BALTIMORE DR
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2648
Mailing Address - Country:US
Mailing Address - Phone:410-907-8500
Mailing Address - Fax:
Practice Address - Street 1:3097 PRESIDENTIAL DR
Practice Address - Street 2:SUITE F
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30340-3914
Practice Address - Country:US
Practice Address - Phone:770-220-1570
Practice Address - Fax:770-220-1571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA176292332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5669770001Medicare NSC