Provider Demographics
NPI:1114902665
Name:THE CUSTOM SOURCE INC
Entity Type:Organization
Organization Name:THE CUSTOM SOURCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLFES
Authorized Official - Suffix:
Authorized Official - Credentials:DHA, ATC
Authorized Official - Phone:704-893-5457
Mailing Address - Street 1:1013 CHESTNUT LN STE 120
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-8567
Mailing Address - Country:US
Mailing Address - Phone:704-893-5457
Mailing Address - Fax:704-973-0696
Practice Address - Street 1:1013 CHESTNUT LN STE 120
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28104-8567
Practice Address - Country:US
Practice Address - Phone:704-893-5457
Practice Address - Fax:704-973-0696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0491EOtherBC/BS/NC
NC7700578Medicaid
0491EOtherBC/BS/NC