Provider Demographics
NPI:1447222054
Name:CUSTOM CARE ORTHOTICS, INC
Entity Type:Organization
Organization Name:CUSTOM CARE ORTHOTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORTHOTIST
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:HENTGES
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:612-871-5000
Mailing Address - Street 1:910 E 26TH ST
Mailing Address - Street 2:460
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4526
Mailing Address - Country:US
Mailing Address - Phone:612-871-5000
Mailing Address - Fax:612-871-3800
Practice Address - Street 1:910 E 26TH ST
Practice Address - Street 2:460
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4526
Practice Address - Country:US
Practice Address - Phone:612-871-5000
Practice Address - Fax:612-871-3800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN82-00444OtherSELECT CARE
MN164659OtherUCARE MINNESOTA
MN165L9CUOtherBLUE CROSS BLUE SHIELD
MN96446OtherHEALTH PARTNERS
MN82-00444OtherUNITED HEALTH CARE
MN01035214OtherPREFERRED ONE
MN82-00444OtherMEDICA
MN82-00444OtherMEDICA