Provider Demographics
NPI:1518138023
Name:CUSTOM CARE THERAPY AND WELLNESS, INC.
Entity Type:Organization
Organization Name:CUSTOM CARE THERAPY AND WELLNESS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:ROBBINS
Authorized Official - Last Name:HOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:318-949-9665
Mailing Address - Street 1:PO BOX 336
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:LA
Mailing Address - Zip Code:71067-0336
Mailing Address - Country:US
Mailing Address - Phone:318-949-9665
Mailing Address - Fax:318-949-3400
Practice Address - Street 1:1151 HIGHWAY 614
Practice Address - Street 2:
Practice Address - City:HAUGHTON
Practice Address - State:LA
Practice Address - Zip Code:71037-8977
Practice Address - Country:US
Practice Address - Phone:318-949-9665
Practice Address - Fax:318-949-3400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPT544261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy