1447222054 NPI number — CUSTOM CARE ORTHOTICS, INC

Table of content: (NPI 1447222054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447222054 NPI number — CUSTOM CARE ORTHOTICS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CUSTOM CARE ORTHOTICS, 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:
Provider Other Organization Name Type Code:
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:
1447222054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
910 E 26TH ST
Provider Second Line Business Mailing Address:
460
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55404-4526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-871-5000
Provider Business Mailing Address Fax Number:
612-871-3800

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 E 26TH ST
Provider Second Line Business Practice Location Address:
460
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55404-4526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-871-5000
Provider Business Practice Location Address Fax Number:
612-871-3800
Provider Enumeration Date:
02/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HENTGES
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
OWNER/ORTHOTIST
Authorized Official Telephone Number:
612-871-5000

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 82-00444 . This is a "SELECT CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 164659 . This is a "UCARE MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 165L9CU . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 96446 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 82-00444 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 01035214 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 82-00444 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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