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General NPI Number Information
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NPI Number | 1932424405
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Entity Type | Organization
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Legal Business Name | CUSTOM REHAB BRACING AND MEDICAL SUPPLY,LLC
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Dates
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Enumeration Date | 03/29/2010
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Last Update Date | 03/29/2010
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Provider Practice Location Address
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Address Line | 721 RIVER PARK DR
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City | SAN JOSE
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State | CA
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Zip | 95111-1552
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Country | US
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Telephone | 408-660-0120
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Fax | 408-333-9632
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Provider Business Mailing Address
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Address Line | 721 RIVER PARK DR
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City | SAN JOSE
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State | CA
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Zip | 95111-1552
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Country | US
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Telephone | 408-660-0120
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Fax | 408-333-9632
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Authorized Official
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Title or Position | OWNER
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Name | MR. ARCADIO RODRIGUEZ RODRIGUEZ
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Credential | O.T
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Telephone | 408-660-0120
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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 | 101-555617
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License Number State | CA
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