Provider Demographics
NPI:1659427870
Name:CUSTOM ORTHOPEDIC INC
Entity Type:Organization
Organization Name:CUSTOM ORTHOPEDIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:DEASE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-355-0337
Mailing Address - Street 1:1271 TALLEVAST RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-3268
Mailing Address - Country:US
Mailing Address - Phone:941-355-0337
Mailing Address - Fax:941-355-0616
Practice Address - Street 1:1271 TALLEVAST RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-3268
Practice Address - Country:US
Practice Address - Phone:941-355-0337
Practice Address - Fax:941-355-0616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1076450001Medicare ID - Type Unspecified