Provider Demographics
NPI:1407047319
Name:CUSTOM OCULAR PROSTHETICS, INC.
Entity Type:Organization
Organization Name:CUSTOM OCULAR PROSTHETICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:OCULARIST
Authorized Official - Phone:520-722-7471
Mailing Address - Street 1:9465 E HARRISON PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-6613
Mailing Address - Country:US
Mailing Address - Phone:520-722-7471
Mailing Address - Fax:
Practice Address - Street 1:9465 E HARRISON PL
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-6613
Practice Address - Country:US
Practice Address - Phone:520-722-7471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNOT REQUIRED BY STAT335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ309543Medicaid
AZ0188390001Medicare NSC