MEDICARE: MALONEY'S CUSTOM OCULAR PROSTHETICS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1700X	Ocularist	2002801	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043360977
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MALONEY'S CUSTOM OCULAR PROSTHETICS, INC.

Provider Business Mailing Address
First Line	:	4500 KRUSE WAY STE 300
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-2563
Country	:	US
Telephone Number	:	503-675-1320
Fax Number	:

Provider Business Practice Location Address
First Line	:	4500 KRUSE WAY STE 300
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-2563
Country	:	US
Telephone Number	:	503-675-1320
Fax Number	:

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	LEXI SCHOU
Credential	:
Telephone Number	:	503-675-1320

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	03/25/2026

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