Healthcare Provider Details

I. General information

NPI: 1053839811
Provider Name (Legal Business Name): CUSTOM FAMILY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 HUGHES RD
MADISON AL
35758-1142
US

IV. Provider business mailing address

279 HUGHES RD
MADISON AL
35758-1142
US

V. Phone/Fax

Practice location:
  • Phone: 256-289-1733
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: IVAN PIVOVAROV
Title or Position: PRESIDENT
Credential: MD
Phone: 256-325-0480