Provider Demographics
NPI:1053555417
Name:ADVANCED CUSTOM ORTHOTICS, INC.
Entity type:Organization
Organization Name:ADVANCED CUSTOM ORTHOTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:B
Authorized Official - Last Name:HAVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-536-2514
Mailing Address - Street 1:17600 CHESTERFIELD AIRPORT RD
Mailing Address - Street 2:STE B5
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1246
Mailing Address - Country:US
Mailing Address - Phone:636-536-2514
Mailing Address - Fax:
Practice Address - Street 1:17600 CHESTERFIELD AIRPORT RD
Practice Address - Street 2:STE B5
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1246
Practice Address - Country:US
Practice Address - Phone:636-536-2514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-28
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
6229500001Medicare NSC