Provider Demographics
NPI:1275583783
Name:CUSTOM HEALTHCARE, LLC
Entity Type:Organization
Organization Name:CUSTOM HEALTHCARE, LLC
Other - Org Name:PPS ORTHOTIC & PROSTHETIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:423-697-0057
Mailing Address - Street 1:3700 BRAINERD RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-3603
Mailing Address - Country:US
Mailing Address - Phone:423-697-0057
Mailing Address - Fax:423-648-9366
Practice Address - Street 1:3700 BRAINERD RD STE 134
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-3603
Practice Address - Country:US
Practice Address - Phone:423-697-0057
Practice Address - Fax:423-648-9366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1036332B00000X, 332BC3200X
TN3347332BX2000X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003113634AMedicaid
GA003199235AMedicaid
TN1455062Medicaid
MS05130009Medicaid
KY7100162230Medicaid
GA000973794CMedicaid