Provider Demographics
NPI:1952451296
Name:CUSTOM HEALTHCARE, LLC
Entity Type:Organization
Organization Name:CUSTOM HEALTHCARE, LLC
Other - Org Name:PPS ORTHOTIC & PROSTHETIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-697-0057
Mailing Address - Street 1:3700 BRAINERD RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-3603
Mailing Address - Country:US
Mailing Address - Phone:423-697-0057
Mailing Address - Fax:423-648-9366
Practice Address - Street 1:2150 N OCOEE ST STE C
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3936
Practice Address - Country:US
Practice Address - Phone:423-559-0013
Practice Address - Fax:423-559-2442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1507472Medicaid
GA000973794CMedicaid
GA000973794CMedicaid