Healthcare Provider Details

I. General information

NPI: 1083195663
Provider Name (Legal Business Name): CUSTOM HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 03/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 12TH ST STE B
PHENIX CITY AL
36867-5827
US

IV. Provider business mailing address

3700 BRAINERD RD
CHATTANOOGA TN
37411-3603
US

V. Phone/Fax

Practice location:
  • Phone: 334-560-5777
  • Fax: 423-648-9366
Mailing address:
  • Phone: 423-697-0057
  • Fax: 423-648-9366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1511
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number1511
License Number StateAL

VIII. Authorized Official

Name: JAMES C ROGERS
Title or Position: CEO
Credential:
Phone: 423-697-0057