Provider Demographics
NPI:1144609009
Name:CUSTOM ORTHOTIC SOLUTIONS, INC.
Entity Type:Organization
Organization Name:CUSTOM ORTHOTIC SOLUTIONS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:RITA
Authorized Official - Last Name:CARLONE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:541-790-2092
Mailing Address - Street 1:784 NANTUCKET AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-2719
Mailing Address - Country:US
Mailing Address - Phone:541-790-2092
Mailing Address - Fax:541-636-5352
Practice Address - Street 1:784 NANTUCKET AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404
Practice Address - Country:US
Practice Address - Phone:541-790-2092
Practice Address - Fax:541-636-5352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-26
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06505261QP2000X
224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500736150Medicaid