MEDICARE: CUSTOM HEALTHCARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1316268105
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CUSTOM HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	1540 GOBER RD
Second Line	:
City	:	BISHOP
State	:	GA
Zip	:	30621-1685
Country	:	US
Telephone Number	:	706-207-1039
Fax Number	:

Provider Business Practice Location Address
First Line	:	1540 GOBER RD
Second Line	:
City	:	BISHOP
State	:	GA
Zip	:	30621-1685
Country	:	US
Telephone Number	:	706-207-1039
Fax Number	:

Authorized Official
Title or Position	:	CEO/ PROVIDER
Name	:	DR. TROY ALLEN HEIDESCH
Credential	:	DNP
Telephone Number	:	706-207-1039

Provider Enumeration Date	:	06/16/2010
Last Update Date	:	06/16/2010

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Directions to “CUSTOM HEALTHCARE LLC ” Practice Location

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