Provider Demographics
NPI:1255417929
Name:CUSTOM ORTHOTICS & PROSTHETICS, LP
Entity type:Organization
Organization Name:CUSTOM ORTHOTICS & PROSTHETICS, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-566-3440
Mailing Address - Street 1:3901 MONTANA AVE STE C
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79903-4507
Mailing Address - Country:US
Mailing Address - Phone:915-566-3440
Mailing Address - Fax:915-566-1485
Practice Address - Street 1:3901 MONTANA AVE STE C
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-4507
Practice Address - Country:US
Practice Address - Phone:915-566-3440
Practice Address - Fax:915-566-1485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224P00000X, 222Z00000X
TX101202335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178724405Medicaid
TX178724401Medicaid
TX178724404Medicaid
TX178724406Medicaid
TX101202OtherTX O&P FACILITY STATE LIC
TX178724407Medicaid