Provider Demographics
NPI:1548343916
Name:CUSTOMFIT PROLABS INC
Entity type:Organization
Organization Name:CUSTOMFIT PROLABS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:THIGPEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPED/CO/ORF
Authorized Official - Phone:954-721-7301
Mailing Address - Street 1:8043 W MCNAB RD
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-3254
Mailing Address - Country:US
Mailing Address - Phone:954-721-7301
Mailing Address - Fax:954-721-7453
Practice Address - Street 1:8043 W MCNAB RD
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-3254
Practice Address - Country:US
Practice Address - Phone:954-721-7301
Practice Address - Fax:954-721-7453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-22
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL335E00000X335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherUNITED HEALTHCARE
FL5695940001Medicare ID - Type UnspecifiedMEDICARE