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General NPI Number Information
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NPI Number | 1699859124
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Entity Type | Organization
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Legal Business Name | CUSTOM CLINIC, P.A.
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Dates
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Enumeration Date | 10/24/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 322 S STATE ST 5 LAKE CENTER DRIVE
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City | FAIRMONT
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State | MN
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Zip | 56031-4139
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Country | US
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Telephone | 507-236-2880
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Fax |
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Provider Business Mailing Address
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Address Line | 322 S STATE ST 5 LAKE CENTER DRIVE
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City | FAIRMONT
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State | MN
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Zip | 56031-4139
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Country | US
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Telephone | 507-236-2880
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | TIMOTHY C BACHENBERG
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Credential | M.D.
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Telephone | 507-236-2880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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