Provider Demographics
NPI:1255570099
Name:CUSTOM DME
Entity type:Organization
Organization Name:CUSTOM DME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:CCA
Authorized Official - Phone:801-997-0545
Mailing Address - Street 1:3474 S 100 E
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6605
Mailing Address - Country:US
Mailing Address - Phone:801-997-0545
Mailing Address - Fax:888-977-5399
Practice Address - Street 1:1455 S 500 W STE D
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-8252
Practice Address - Country:US
Practice Address - Phone:801-997-0545
Practice Address - Fax:888-977-5399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes229N00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersAnaplastologistGroup - Multi-Specialty
No156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularistGroup - Multi-Specialty