=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639130990
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CUSTOM ARTIFICIAL LIMB AND BRACE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 WILMINGTON AVE
-----------------------------------------------------
City | NEW CASTLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16101-2142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-654-3991
-----------------------------------------------------
Fax | 724-654-2447
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 WILMINGTON AVE
-----------------------------------------------------
City | NEW CASTLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16101-2142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-654-3991
-----------------------------------------------------
Fax | 724-654-2447
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JOSEPH P REAGLE
-----------------------------------------------------
Credential | C.P.O.
-----------------------------------------------------
Telephone | 724-654-3991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------