Healthcare Provider Details

I. General information

NPI: 1114902665
Provider Name (Legal Business Name): THE CUSTOM SOURCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 CHESTNUT LN STE 120
MATTHEWS NC
28104-8567
US

IV. Provider business mailing address

1013 CHESTNUT LN STE 120
MATTHEWS NC
28104-8567
US

V. Phone/Fax

Practice location:
  • Phone: 704-893-5457
  • Fax: 704-973-0696
Mailing address:
  • Phone: 704-893-5457
  • Fax: 704-973-0696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: KASEY ROLFES
Title or Position: OPERATIONS MANAGER
Credential: DHA, ATC
Phone: 704-893-5457