Provider Demographics
NPI:1710022678
Name:CUSTOM CARE MEDICAL, LLC
Entity Type:Organization
Organization Name:CUSTOM CARE MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:EVA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNZ
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:717-564-0564
Mailing Address - Street 1:463 E MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:MYERSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17067-2226
Mailing Address - Country:US
Mailing Address - Phone:717-272-4967
Mailing Address - Fax:717-564-3135
Practice Address - Street 1:463 E MAIN AVE
Practice Address - Street 2:
Practice Address - City:MYERSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17067-2226
Practice Address - Country:US
Practice Address - Phone:717-272-4967
Practice Address - Fax:717-564-3135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABL5564340207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG70356Medicare UPIN
PA009750Medicare PIN