Provider Demographics
NPI:1306093463
Name:CUSTOM MEDICAL EQUIPMENT LLC
Entity type:Organization
Organization Name:CUSTOM MEDICAL EQUIPMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOSEPHINE
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:CZERNY
Authorized Official - Suffix:
Authorized Official - Credentials:CRTS
Authorized Official - Phone:218-326-2212
Mailing Address - Street 1:1001 S POKEGAMA AVE STE A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3919
Mailing Address - Country:US
Mailing Address - Phone:218-326-2212
Mailing Address - Fax:
Practice Address - Street 1:1001 S POKEGAMA AVE STE A
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3919
Practice Address - Country:US
Practice Address - Phone:218-326-2212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-20
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9615269332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN697697100Medicaid
MN6154520001Medicare NSC