Provider Demographics
NPI:1053839811
Name:CUSTOM FAMILY CARE, LLC
Entity Type:Organization
Organization Name:CUSTOM FAMILY CARE, LLC
Other - Org Name:CUSTOM FAMILY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PIVOVAROV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-325-0480
Mailing Address - Street 1:279 HUGHES RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-1142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:279 HUGHES RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-1142
Practice Address - Country:US
Practice Address - Phone:256-289-1733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-31
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty