Provider Demographics
NPI:1700135852
Name:DALLAS CUSTOM ORTHOTICS LLC
Entity Type:Organization
Organization Name:DALLAS CUSTOM ORTHOTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-497-7782
Mailing Address - Street 1:17600 CHESTERFIELD AIRPORT RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1246
Mailing Address - Country:US
Mailing Address - Phone:314-497-7782
Mailing Address - Fax:
Practice Address - Street 1:2817 REGAL RD
Practice Address - Street 2:SUITE 109
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-6444
Practice Address - Country:US
Practice Address - Phone:214-507-4015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment