Healthcare Provider Details

I. General information

NPI: 1477736353
Provider Name (Legal Business Name): CUSTOM OCULAR PROSTHETICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S MAIN ST SUITE B6
ALPHARETTA GA
30009-1974
US

IV. Provider business mailing address

401 S MAIN ST SUITE B6
ALPHARETTA GA
30009-1974
US

V. Phone/Fax

Practice location:
  • Phone: 770-667-1166
  • Fax: 770-667-1188
Mailing address:
  • Phone: 770-667-1166
  • Fax: 770-667-1188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. ANTONIO LOUIS ALCORTA I
Title or Position: OWNER
Credential: BCO
Phone: 559-940-1189