Healthcare Provider Details

I. General information

NPI: 1912440843
Provider Name (Legal Business Name): FREDERICK CUSTOMEYEZ PROSTHETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2016
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1422 EUCLID AVE SUITE 802
CLEVELAND OH
44115-1902
US

IV. Provider business mailing address

9278 PARADISE DR
PANAMA CITY BEACH FL
32413-9625
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberO.24
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number
License Number StateNULL

VIII. Authorized Official

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