Basic Information
| Provider Information | |||||||||
| NPI: | 1366900391 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CUSTOM HEALTHCARE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHOENIX REHAB & MOBILITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3700 BRAINERD RD | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374113603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236970057 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 410 DROMEDARY ST | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302933560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704504227 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2019 | ||||||||
| LastUpdateDate: | 03/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | ROGERS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4236970057 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BC3200X | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
No ID Information.