Basic Information
| Provider Information | |||||||||
| NPI: | 1275583783 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CUSTOM HEALTHCARE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PPS ORTHOTIC & PROSTHETIC SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3700 BRAINERD RD | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374113603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236970057 | ||||||||
| FaxNumber: | 4236489366 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 BRAINERD RD STE 134 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374113603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236970057 | ||||||||
| FaxNumber: | 4236489366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROGERS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4236970057 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 1036 | TN | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BX2000X | 3347 | TN | N | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies | 332BC3200X | 1036 | TN | N | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 335E00000X | Y | Suppliers | Prosthetic/Orthotic Supplier |
ID Information
| ID | Type | State | Issuer | Description | 003113634A | 05 | GA | MEDICAID | 003199235A | 05 | GA | MEDICAID | 1455062 | 05 | TN | MEDICAID | 05130009 | 05 | MS | MEDICAID | 7100162230 | 05 | KY | MEDICAID | 000973794C | 05 | GA | MEDICAID |