Custom Brace Shop INC.
Durable Medical Equipment & Medical Supplies in Galesburg, IL. Organization (NPI-2).
NPI number1306865563
StatusActive
Last updated in NPPESJul 11, 2008
Details
- NPI
- 1306865563
- Entity type
- Organization (NPI-2)
- Legal business name
- Custom Brace Shop INC.
- Organization subpart
- No
- Enumeration date
- Jul 19, 2006
- Last updated
- Jul 11, 2008
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 332B00000X | Durable Medical Equipment & Medical Supplies | – | – | Yes |
Practice location
872 W Dayton StGalesburg, IL 61401-1503
Phone 309-344-5330 · Fax 309-344-5040
Mailing address
872 W Dayton StGalesburg, IL 61401-1503
Phone 309-344-5330 · Fax 309-344-5040
Authorized official
Fakhry Wilson Azer
President /Owner
3093443400
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