Provider Demographics
NPI:1306865563
Name:CUSTOM BRACE SHOP INC.
Entity Type:Organization
Organization Name:CUSTOM BRACE SHOP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT /OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FAKHRY
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:AZER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:309-344-3400
Mailing Address - Street 1:872 W DAYTON ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-1503
Mailing Address - Country:US
Mailing Address - Phone:309-344-5330
Mailing Address - Fax:309-344-5040
Practice Address - Street 1:872 W DAYTON ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-1503
Practice Address - Country:US
Practice Address - Phone:309-344-5330
Practice Address - Fax:309-344-5040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL30404878OtherCERTIFICATE OF REGISTRATI
IL1284320001Medicare NSC