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General NPI Number Information
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NPI Number | 1447222054
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Entity Type | Organization
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Legal Business Name | CUSTOM CARE ORTHOTICS, INC
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Dates
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Enumeration Date | 02/07/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 910 E 26TH ST 460
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City | MINNEAPOLIS
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State | MN
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Zip | 55404-4526
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Country | US
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Telephone | 612-871-5000
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Fax | 612-871-3800
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Provider Business Mailing Address
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Address Line | 910 E 26TH ST 460
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City | MINNEAPOLIS
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State | MN
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Zip | 55404-4526
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Country | US
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Telephone | 612-871-5000
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Fax | 612-871-3800
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Authorized Official
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Title or Position | OWNER/ORTHOTIST
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Name | CAROL JEAN HENTGES
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Credential | C.O.
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Telephone | 612-871-5000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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