Provider Demographics
NPI:1841402377
Name:A CUSTOM COMFORT SHOES INC
Entity type:Organization
Organization Name:A CUSTOM COMFORT SHOES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:DULBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-457-1202
Mailing Address - Street 1:800 E HALLANDALE BEACH BLVD
Mailing Address - Street 2:SUITE 23
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-4477
Mailing Address - Country:US
Mailing Address - Phone:954-457-1202
Mailing Address - Fax:954-454-9971
Practice Address - Street 1:800 E HALLANDALE BEACH BLVD
Practice Address - Street 2:SUITE 23
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-4477
Practice Address - Country:US
Practice Address - Phone:954-457-1202
Practice Address - Fax:954-454-9971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPED15335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM1031OtherBLUECROSS BLUESHIELD
FL0588670001Medicare NSC