MEDICARE: CLT CUSTOM CRANIAL PROSTHESIS

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	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1891621587
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLT CUSTOM CRANIAL PROSTHESIS

Provider Business Mailing Address
First Line	:	3709 EASTWAY DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-6266
Country	:	US
Telephone Number	:	704-996-7818
Fax Number	:	980-430-3075

Provider Business Practice Location Address
First Line	:	3709 EASTWAY DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-6266
Country	:	US
Telephone Number	:	704-996-7818
Fax Number	:	980-430-3075

Authorized Official
Title or Position	:	CEO
Name	:	PAULA GRAY
Credential	:	GRAY
Telephone Number	:	704-996-7818

Provider Enumeration Date	:	06/20/2026
Last Update Date	:	06/20/2026

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