| Organization Name: | CUSTOM HEALTHCARE LLC |
| NPI Number: | 1316268105 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TROY ALLEN HEIDESCH (CEO/ PROVIDER) |
| Mailing Address: | 1540 Gober Rd Bishop |
| State: | GA US |
| Postal Code: | 306211685 |
| Phone Number: | 7062071039 |
| Fax Number: | |
| NPI Enumeration Date: | 06/16/2010 |
| NPI Last Update Date: | 06/16/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QM1300X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Multi-Specialty |
| Taxonomy Definition: | |