MEDICARE: CUSTOM HEALTHCARE OF GEORGIA LLC

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	332BC3200X	Customized Equipment (DME)	176292	GA

General Provider Information

NPI Number	:	1154334266
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CUSTOM HEALTHCARE OF GEORGIA LLC

Provider Business Mailing Address
First Line	:	2700 LORD BALTIMORE DR
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21244-2648
Country	:	US
Telephone Number	:	410-907-8500
Fax Number	:

Provider Business Practice Location Address
First Line	:	3097 PRESIDENTIAL DR
Second Line	:	SUITE F
City	:	ATLANTA
State	:	GA
Zip	:	30340-3914
Country	:	US
Telephone Number	:	770-220-1570
Fax Number	:	770-220-1571

Authorized Official
Title or Position	:	CFO
Name	:	TAMAS FEITEL
Credential	:
Telephone Number	:	860-257-3443

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	08/19/2016

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