1699859124 NPI number — CUSTOM CLINIC, P.A.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699859124 NPI number — CUSTOM CLINIC, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CUSTOM CLINIC, P.A.
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:
6
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:
1699859124
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:
322 S STATE ST
Provider Second Line Business Mailing Address:
5 LAKE CENTER DRIVE
Provider Business Mailing Address City Name:
FAIRMONT
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56031-4139
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-236-2880
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
322 S STATE ST
Provider Second Line Business Practice Location Address:
5 LAKE CENTER DRIVE
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56031-4139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-236-2880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/24/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BACHENBERG
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
507-236-2880

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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