Healthcare Provider Details

I. General information

NPI: 1891621587
Provider Name (Legal Business Name): CLT CUSTOM CRANIAL PROSTHESIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2026
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3709 EASTWAY DR
CHARLOTTE NC
28205-6266
US

IV. Provider business mailing address

3709 EASTWAY DR
CHARLOTTE NC
28205-6266
US

V. Phone/Fax

Practice location:
  • Phone: 704-996-7818
  • Fax: 980-430-3075
Mailing address:
  • Phone: 704-996-7818
  • Fax: 980-430-3075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: PAULA GRAY
Title or Position: CEO
Credential: GRAY
Phone: 704-996-7818