1922143023 NPI number — CUSTOM HEALTHCARE INC

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 1922143023 NPI number — CUSTOM HEALTHCARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CUSTOM HEALTHCARE 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:
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:
1922143023
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 BROOK ST STE 402
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKY HILL
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06067-3431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-447-7500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1701 OLD MINDEN RD STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSSIER CITY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71111-4849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-752-2273
Provider Business Practice Location Address Fax Number:
318-752-2275
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VILLESCAS
Authorized Official First Name:
SONIA
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
SR MGR LICENSING & CREDENTIALING
Authorized Official Telephone Number:
314-447-7515

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BC3200X , with the licence number: 06-08770 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BC3200X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 209553716 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1877755-02 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1673552 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1877755-04 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 187775501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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