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General NPI Number Information
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NPI Number | 1306093463
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Entity Type | Organization
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Legal Business Name | CUSTOM MEDICAL EQUIPMENT LLC
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Dates
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Enumeration Date | 08/20/2008
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Last Update Date | 08/19/2022
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Provider Practice Location Address
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Address Line | 1001 S POKEGAMA AVE STE A
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City | GRAND RAPIDS
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State | MN
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Zip | 55744-3919
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Country | US
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Telephone | 218-326-2212
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Fax |
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Provider Business Mailing Address
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Address Line | 1001 S POKEGAMA AVE STE A
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City | GRAND RAPIDS
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State | MN
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Zip | 55744-3919
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Country | US
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Telephone | 218-326-2212
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. JOSEPHINE LYN CZERNY
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Credential | CRTS
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Telephone | 218-326-2212
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number | 9615269
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License Number State | MN
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