Provider Demographics
NPI:1093232811
Name:CUSTOM ORTHOPEDIC SUPPLY LLC
Entity Type:Organization
Organization Name:CUSTOM ORTHOPEDIC SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FAIGY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-550-8515
Mailing Address - Street 1:100 LAWRENCE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-5033
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 LAWRENCE STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:NANUET
Practice Address - State:NY
Practice Address - Zip Code:10954
Practice Address - Country:US
Practice Address - Phone:650-550-8515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies