MEDICARE: CUSTOM CE 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	1744P3200X	Prosthetics Case Management

General Provider Information

NPI Number	:	1609474535
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CUSTOM CE LLC

Provider Business Mailing Address
First Line	:	4224 CHAMBERS ST
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45223-1826
Country	:	US
Telephone Number	:	513-331-3071
Fax Number	:

Provider Business Practice Location Address
First Line	:	4224 CHAMBERS ST
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45223-1826
Country	:	US
Telephone Number	:	513-331-3071
Fax Number	:

Authorized Official
Title or Position	:	EDUCATIONAL DIRECTOR
Name	:	JASMINE PATRICE DAVIS
Credential	:	CERTIFIED HAIR LOSS
Telephone Number	:	513-331-3071

Provider Enumeration Date	:	10/13/2020
Last Update Date	:	10/15/2020

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Directions to “CUSTOM CE LLC ” Practice Location

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