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Organization
CUSTOM TRT US INC
Active
Organization
CUSTOM TRT US INC
Active
Other names
Custom TRT
Organization subpart
No
Provider details
NPI number
Authorized official
AMANDA WIERMANN PA (PRESIDENT)
(516) 652-6509
Entity
Organization
Contact information
Practice address
69 CLYMER STREET, PORT JEFFERSON STATION, NY 11776
(631) 260-1945
(631) 403-1298
Mailing address
P.O. BOX 263, PORT JEFFERSON STATION, NY 11776
(516) 652-6509
Taxonomy
Speciality
Code
Description
License number
State
261QM2500X
Medical Specialty Clinic/Center
Primary
—
NULL
Other
Enumeration date
11/21/2024
Last updated
11/21/2024
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