MEDICARE: CUSTOM OCULAR PROSTHETICS 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	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1770145138
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CUSTOM OCULAR PROSTHETICS LLC

Provider Business Mailing Address
First Line	:	10212 5TH AVE NE STE 210
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98125-7471
Country	:	US
Telephone Number	:	206-522-4222
Fax Number	:	206-525-1496

Provider Business Practice Location Address
First Line	:	10212 5TH AVE NE STE 210
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98125-7471
Country	:	US
Telephone Number	:	206-522-4222
Fax Number	:	206-525-1496

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	BRIAN E KOCESKI
Credential	:
Telephone Number	:	206-522-4222

Provider Enumeration Date	:	07/05/2019
Last Update Date	:	03/10/2026

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