Provider Demographics
NPI:1710008537
Name:CUSTOM PROSTHETIC, LTD.
Entity Type:Organization
Organization Name:CUSTOM PROSTHETIC, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, ANAPLASTOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAGGERTY
Authorized Official - Suffix:
Authorized Official - Credentials:MAMS
Authorized Official - Phone:253-327-6192
Mailing Address - Street 1:705 OPERA ALY STE K
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-3734
Mailing Address - Country:US
Mailing Address - Phone:253-327-1924
Mailing Address - Fax:206-826-1790
Practice Address - Street 1:705 OPERA ALY STE K
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3734
Practice Address - Country:US
Practice Address - Phone:253-327-1924
Practice Address - Fax:206-826-1790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes229N00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersAnaplastologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9044017Medicaid
WA0170345OtherLABOR & INDUSTRIES