Custom Brace Shop Inc.

Primary specialty

Durable Medical Equipment & Medical SuppliesTaxonomy code 332B00000X

Legal business name

CUSTOM BRACE SHOP INC.

Practice address

872 W Dayton St
Galesburg, IL 61401-1503

Phone

(309) 344-5330

Fax

(309) 344-5040

NPI assigned

Jul 19, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Fakhry Wilson Azer, P.T.NPI 1790703452

Title

President /Owner

Phone

(309) 344-3400

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Fakhry Wilson Azer, P.T.

  • Physical Therapist
  • Galesburg, IL
  • NPI 1790703452
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153267200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1215734400000",
    "number": "1306865563",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "872 W DAYTON ST",
            "city": "GALESBURG",
            "state": "IL",
            "postal_code": "614011503",
            "telephone_number": "309-344-5330",
            "fax_number": "309-344-5040"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "872 W DAYTON ST",
            "city": "GALESBURG",
            "state": "IL",
            "postal_code": "614011503",
            "telephone_number": "309-344-5330",
            "fax_number": "309-344-5040"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CUSTOM BRACE SHOP INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-19",
        "last_updated": "2008-07-11",
        "status": "A",
        "authorized_official_last_name": "AZER",
        "authorized_official_first_name": "FAKHRY",
        "authorized_official_middle_name": "WILSON",
        "authorized_official_title_or_position": "PRESIDENT /OWNER",
        "authorized_official_telephone_number": "309-344-3400",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "P.T."
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CERTIFICATE OF REGISTRATI",
            "identifier": "30404878",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Cssgaca, LLC
• Emily Cueno, OT
• Robert Currie, M.D.
• Valerie Currier, PHARMD
• Shelly Curtis, LPN
• Julia L Dalmasso, M.S., CCC-SLP
• Mark Davis, M.D.,F.A.C.S.
• Brittany Dean, QMHP
• Julie Ann Debacker, OTL
• Emily L Dechow, APN

• Durable Medical Equipment & Medical Supplies in Galesburg, IL
• Providers in Galesburg, IL by specialty
• Durable Medical Equipment & Medical Supplies in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 11, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.