Healthcare Provider Details

I. General information

NPI: 1841926599
Provider Name (Legal Business Name): FREDERICK CUSTOMEYEZ PROSTHETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1834 CRAIG RD
SAINT LOUIS MO
63146-4712
US

IV. Provider business mailing address

PO BOX 27802
SAINT LOUIS MO
63146-1302
US

V. Phone/Fax

Practice location:
  • Phone: 401-584-3939
  • Fax: 216-678-9186
Mailing address:
  • Phone: 401-584-3939
  • Fax: 216-678-9186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number
License Number State

VIII. Authorized Official

Name: MELISSA FREDERICK
Title or Position: OWNER
Credential:
Phone: 401-584-3939