Provider Demographics
NPI:1467557108
Name:CUSTOM REHABILITATION SPECIALITES, INC
Entity Type:Organization
Organization Name:CUSTOM REHABILITATION SPECIALITES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:SIDNEY
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-471-2962
Mailing Address - Street 1:7225 ANACA POINT RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-9501
Mailing Address - Country:US
Mailing Address - Phone:910-471-2962
Mailing Address - Fax:910-791-7304
Practice Address - Street 1:4308 MAIDSTONE DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-7455
Practice Address - Country:US
Practice Address - Phone:910-228-9808
Practice Address - Fax:910-791-7304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
DE2055335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7701331Medicaid
NC045NXOtherBCBS OF NC
NC0793860001Medicare ID - Type Unspecified