Provider Demographics
NPI:1770145138
Name:CUSTOM OCULAR PROSTHETICS LLC
Entity type:Organization
Organization Name:CUSTOM OCULAR PROSTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:KOCESKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-522-4222
Mailing Address - Street 1:10212 5TH AVE NE STE 210
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-7471
Mailing Address - Country:US
Mailing Address - Phone:206-522-4222
Mailing Address - Fax:206-525-1496
Practice Address - Street 1:10212 5TH AVE NE STE 210
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-7471
Practice Address - Country:US
Practice Address - Phone:206-522-4222
Practice Address - Fax:206-525-1496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-05
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularistGroup - Single Specialty