Provider Demographics
NPI:1073107017
Name:CUSTOM CARE HEALTHCARE, INC.
Entity Type:Organization
Organization Name:CUSTOM CARE HEALTHCARE, INC.
Other - Org Name:CUSTOM CARE HOME HEALTH - FT. WORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-401-1369
Mailing Address - Street 1:6410 SOUTHWEST BLVD STE 127
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76109-6918
Mailing Address - Country:US
Mailing Address - Phone:817-847-8888
Mailing Address - Fax:
Practice Address - Street 1:6410 SOUTHWEST BLVD STE 127
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76109-6918
Practice Address - Country:US
Practice Address - Phone:817-847-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-20
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health