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General NPI Number Information
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NPI Number | 1306865563
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Entity Type | Organization
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Legal Business Name | CUSTOM BRACE SHOP INC.
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Dates
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Enumeration Date | 07/19/2006
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Last Update Date | 07/11/2008
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Provider Practice Location Address
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Address Line | 872 W DAYTON ST
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City | GALESBURG
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State | IL
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Zip | 61401-1503
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Country | US
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Telephone | 309-344-5330
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Fax | 309-344-5040
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Provider Business Mailing Address
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Address Line | 872 W DAYTON ST
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City | GALESBURG
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State | IL
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Zip | 61401-1503
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Country | US
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Telephone | 309-344-5330
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Fax | 309-344-5040
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Authorized Official
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Title or Position | PRESIDENT /OWNER
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Name | MR. FAKHRY WILSON AZER
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Credential | P.T.
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Telephone | 309-344-3400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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