1467823815 NPI number — CUSTOM MED, LLC

Table of content: (NPI 1467823815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467823815 NPI number — CUSTOM MED, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CUSTOM MED, LLC
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:
CUSTOM MED PLUS
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:
1467823815
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4312 N PULASKI
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60641
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-289-6721
Provider Business Mailing Address Fax Number:
779-803-0170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4312 N PULASKI
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-289-6721
Provider Business Practice Location Address Fax Number:
779-803-0170
Provider Enumeration Date:
10/12/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DAHABRA
Authorized Official First Name:
INAS
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
708-289-6721

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  054019489 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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