Provider Demographics
NPI:1477736353
Name:CUSTOM OCULAR PROSTHETICS INC
Entity type:Organization
Organization Name:CUSTOM OCULAR PROSTHETICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:ALCORTA
Authorized Official - Suffix:I
Authorized Official - Credentials:BCO
Authorized Official - Phone:559-940-1189
Mailing Address - Street 1:401 S MAIN ST
Mailing Address - Street 2:SUITE B6
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-1974
Mailing Address - Country:US
Mailing Address - Phone:770-667-1166
Mailing Address - Fax:770-667-1188
Practice Address - Street 1:401 S MAIN ST
Practice Address - Street 2:SUITE B6
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-1974
Practice Address - Country:US
Practice Address - Phone:770-667-1166
Practice Address - Fax:770-667-1188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularistGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00062048AMedicaid
GA0643070001Medicare NSC