1932127396 NPI number — CUSTOM ORTHOTICS OF NORTH CAROLINA, 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 1932127396 NPI number — CUSTOM ORTHOTICS OF NORTH CAROLINA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CUSTOM ORTHOTICS OF NORTH CAROLINA, 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:
1932127396
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:
4125 BEN FRANKLIN BLVD
Provider Second Line Business Mailing Address:
SUITE 180
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27704-2167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-479-5990
Provider Business Mailing Address Fax Number:
919-479-8782

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4125 BEN FRANKLIN BLVD
Provider Second Line Business Practice Location Address:
SUITE 180
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27704-2167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-479-5990
Provider Business Practice Location Address Fax Number:
919-479-8782
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEAL
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
BRADLEY
Authorized Official Title or Position:
OPERATIONS MANAGER, ORTHOTIST
Authorized Official Telephone Number:
919-479-5990

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X , with the licence number:  C18399 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 046P3 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7704266 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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