Provider Demographics
NPI:1699859124
Name:CUSTOM CLINIC, P.A.
Entity Type:Organization
Organization Name:CUSTOM CLINIC, P.A.
Other - Org Name:SMART CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BACHENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:507-236-2880
Mailing Address - Street 1:322 S STATE ST
Mailing Address - Street 2:5 LAKE CENTER DRIVE
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4139
Mailing Address - Country:US
Mailing Address - Phone:507-236-2880
Mailing Address - Fax:
Practice Address - Street 1:322 S STATE ST
Practice Address - Street 2:5 LAKE CENTER DRIVE
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4139
Practice Address - Country:US
Practice Address - Phone:507-236-2880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty