Provider Demographics
NPI:1912603507
Name:FREDERICK CUSTOMEYEZ IN ST. LOUIS
Entity Type:Organization
Organization Name:FREDERICK CUSTOMEYEZ IN ST. LOUIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-584-3939
Mailing Address - Street 1:6005 LAFAYETTE DR
Mailing Address - Street 2:
Mailing Address - City:WELDON SPRING
Mailing Address - State:MO
Mailing Address - Zip Code:63304-7890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1834 CRAIG RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-4712
Practice Address - Country:US
Practice Address - Phone:401-584-3939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREDERICK CUSTOMEYEZ PROSTHETICS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center