1114930138 NPI number — CUSTOM HEALTHCARE INC

Table of content: (NPI 1114930138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114930138 NPI number — CUSTOM HEALTHCARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CUSTOM HEALTHCARE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NUMOTION
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114930138
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 BROOK ST STE 402
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKY HILL
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06067-3431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-447-7500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11725 INDUSTRIPLEX BLVD
Provider Second Line Business Practice Location Address:
UNIT 4
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70809-5190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-753-7007
Provider Business Practice Location Address Fax Number:
225-753-7037
Provider Enumeration Date:
08/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
WALTER
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING AND LICENSURE MANAGER
Authorized Official Telephone Number:
314-447-7515

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BC3200X , with the licence number: 400538 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1673552 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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