Healthcare Provider Details

I. General information

NPI: 1144609009
Provider Name (Legal Business Name): CUSTOM ORTHOTIC SOLUTIONS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

784 NANTUCKET AVE
EUGENE OR
97404
US

IV. Provider business mailing address

784 NANTUCKET AVE
EUGENE OR
97404-2719
US

V. Phone/Fax

Practice location:
  • Phone: 541-790-2092
  • Fax: 541-636-5352
Mailing address:
  • Phone: 541-790-2092
  • Fax: 541-636-5352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number06505
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500736150
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: MELANIE RITA CARLONE
Title or Position: OWNER/PROVIDER
Credential: PT
Phone: 541-790-2092