Healthcare Provider Details

I. General information

NPI: 1124776828
Provider Name (Legal Business Name): KUSTOM MADE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2022
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21841 KENOSHA ST
OAK PARK MI
48237-2651
US

IV. Provider business mailing address

21841 KENOSHA ST
OAK PARK MI
48237-2651
US

V. Phone/Fax

Practice location:
  • Phone: 248-890-9660
  • Fax:
Mailing address:
  • Phone: 248-890-9660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MS. PATRICE COATES
Title or Position: CEO
Credential:
Phone: 248-890-9660