Provider Demographics
NPI:1720592884
Name:CUSTOM CHIROPRACTIC SERVICES LLC
Entity Type:Organization
Organization Name:CUSTOM CHIROPRACTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:FRANK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-768-8726
Mailing Address - Street 1:1710 BRYAN ST # 1
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-4412
Mailing Address - Country:US
Mailing Address - Phone:321-768-8005
Mailing Address - Fax:
Practice Address - Street 1:1710 BRYAN ST # 1
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4412
Practice Address - Country:US
Practice Address - Phone:321-768-8005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12332111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty