Provider Demographics
NPI:1316268105
Name:CUSTOM HEALTHCARE LLC
Entity type:Organization
Organization Name:CUSTOM HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HEIDESCH
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:706-207-1039
Mailing Address - Street 1:1540 GOBER RD
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:GA
Mailing Address - Zip Code:30621-1685
Mailing Address - Country:US
Mailing Address - Phone:706-207-1039
Mailing Address - Fax:
Practice Address - Street 1:1540 GOBER RD
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:GA
Practice Address - Zip Code:30621-1685
Practice Address - Country:US
Practice Address - Phone:706-207-1039
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1346229622Medicare UPIN
GA1215917182Medicare UPIN