Provider Demographics
NPI:1780600221
Name:CUSTOM CARE OF ELLSWORTH, INC
Entity type:Organization
Organization Name:CUSTOM CARE OF ELLSWORTH, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:W
Authorized Official - Last Name:EDDINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-445-3500
Mailing Address - Street 1:2301 HIGHWAY 1187
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6124
Mailing Address - Country:US
Mailing Address - Phone:817-469-6739
Mailing Address - Fax:
Practice Address - Street 1:802 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KS
Practice Address - Zip Code:67665-1937
Practice Address - Country:US
Practice Address - Phone:785-445-3500
Practice Address - Fax:785-445-3502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSA027002251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS177191Medicare Oscar/Certification
KS100242030AMedicaid
KS100021380AMedicaid
KS100021380BMedicaid