1750772372 NPI number — CUSTOMIZED HEALTHCARE SOLUTIONS LLC

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 1750772372 NPI number — CUSTOMIZED HEALTHCARE SOLUTIONS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CUSTOMIZED HEALTHCARE SOLUTIONS 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:
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:
1750772372
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6053 SPINNAKER LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LADY LAKE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32159-5922
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-552-2181
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1509 SOUTH ST STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34748-6664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-552-2181
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/18/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BOSTAPH
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
352-552-2181

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH8400 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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