Provider Demographics
NPI:1710147301
Name:CUSTOM PROSTHETIC & ORTHOTIC
Entity Type:Organization
Organization Name:CUSTOM PROSTHETIC & ORTHOTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOHNNIE
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:CHILD CARE
Authorized Official - Phone:601-906-1024
Mailing Address - Street 1:801 E NORTHSIDE DR
Mailing Address - Street 2:SUITE - D
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-3663
Mailing Address - Country:US
Mailing Address - Phone:601-906-1024
Mailing Address - Fax:
Practice Address - Street 1:801 E NORTHSIDE DR
Practice Address - Street 2:SUITE - D
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-3663
Practice Address - Country:US
Practice Address - Phone:601-906-1024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-17
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier