Healthcare Provider Details

I. General information

NPI: 1811401672
Provider Name (Legal Business Name): CUSTOM ORTHOTIC SOLUTIONS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2017
Last Update Date: 03/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

784 NANTUCKET AVE
EUGENE OR
97404-2719
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:

VIII. Authorized Official

Name: MRS. DAWN LYNNETTE JONES
Title or Position: CPC
Credential: BS, CPC
Phone: 541-883-7798