1760870745 NPI number — CUSTOMIZED MEDICAL LLC

Table of content: (NPI 1760870745)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760870745 NPI number — CUSTOMIZED MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CUSTOMIZED MEDICAL 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:
1760870745
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
32 EDINBURG LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRUMBULL
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06611-1065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
181 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
NORWALK
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06851-3626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-331-2098
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/29/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BERNTSEN
Authorized Official First Name:
CHRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
203-331-2098

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  CSW0003398 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CSW0003398 . This is a "DEPT. OF CONSUMER PROTECTION" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com