Provider Demographics
NPI:1689867160
Name:CUSTOM FAMILY FOOTWORKS,, LLC
Entity Type:Organization
Organization Name:CUSTOM FAMILY FOOTWORKS,, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-207-4403
Mailing Address - Street 1:63 E PENNINGTON ST STE 106
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85701-1534
Mailing Address - Country:US
Mailing Address - Phone:502-228-4048
Mailing Address - Fax:502-882-4048
Practice Address - Street 1:63 E PENNINGTON ST STE 106
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85701-1534
Practice Address - Country:US
Practice Address - Phone:502-228-4048
Practice Address - Fax:502-882-4048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
5971630001Medicare NSC