Provider Demographics
NPI:1922143023
Name:CUSTOM HEALTHCARE INC
Entity Type:Organization
Organization Name:CUSTOM HEALTHCARE INC
Other - Org Name:NUMOTION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING AND LICENSURE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-447-7515
Mailing Address - Street 1:805 BROOK ST STE 402
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-3431
Mailing Address - Country:US
Mailing Address - Phone:314-447-7500
Mailing Address - Fax:
Practice Address - Street 1:1701 OLD MINDEN RD STE 6
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-4849
Practice Address - Country:US
Practice Address - Phone:318-752-2273
Practice Address - Fax:318-752-2275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
LA06-08770332BC3200X
TX332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR209553716Medicaid
LA1673552Medicaid
TX187775501Medicaid