Healthcare Provider Details

I. General information

NPI: 1215058086
Provider Name (Legal Business Name): CUSTOM SPECIALTY PRODUCTS, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 UNION AVE
PROVIDENCE RI
02909-4808
US

IV. Provider business mailing address

490 UNION AVE
PROVIDENCE RI
02909-4808
US

V. Phone/Fax

Practice location:
  • Phone: 401-942-1773
  • Fax: 401-944-5571
Mailing address:
  • Phone: 401-942-1773
  • Fax: 401-944-5571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number15710
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number15710
License Number StateRI

VIII. Authorized Official

Name: MRS. BARBARA MCNAMARA
Title or Position: CEO & PRES.
Credential:
Phone: 401-942-1773