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General NPI Number Information
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NPI Number | 1114902665
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Entity Type | Organization
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Legal Business Name | THE CUSTOM SOURCE INC
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Dates
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Enumeration Date | 12/07/2005
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1013 CHESTNUT LN STE 120
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City | MATTHEWS
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State | NC
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Zip | 28104-8567
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Country | US
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Telephone | 704-893-5457
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Fax | 704-973-0696
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Provider Business Mailing Address
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Address Line | 1013 CHESTNUT LN STE 120
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City | MATTHEWS
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State | NC
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Zip | 28104-8567
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Country | US
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Telephone | 704-893-5457
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Fax | 704-973-0696
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Authorized Official
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Title or Position | OPERATIONS MANAGER
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Name | KASEY ROLFES
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Credential | DHA, ATC
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Telephone | 704-893-5457
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 222Z00000X
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Taxonomy Name | Orthotist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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