Healthcare Provider Details

I. General information

NPI: 1770145138
Provider Name (Legal Business Name): CUSTOM OCULAR PROSTHETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10212 5TH AVE NE STE 210
SEATTLE WA
98125-7471
US

IV. Provider business mailing address

10212 5TH AVE NE STE 210
SEATTLE WA
98125-7471
US

V. Phone/Fax

Practice location:
  • Phone: 206-522-4222
  • Fax: 206-525-1496
Mailing address:
  • Phone: 206-522-4222
  • Fax: 206-525-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BRIAN E KOCESKI
Title or Position: OFFICE MANAGER
Credential:
Phone: 206-522-4222