Organization
THE CUSTOM SOURCE INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KASEY ROLFES DHA, ATC (OPERATIONS MANAGER)
(704) 893-5457
Entity
Organization
Contact information
Practice address
1013 CHESTNUT LN STE 120, MATTHEWS, NC 28104-8567
(704) 893-5457
(704) 973-0696
Mailing address
1013 CHESTNUT LN STE 120, MATTHEWS, NC 28104-8567
(704) 893-5457
(704) 973-0696
Taxonomy
Speciality
Code
Description
License number
State
222Z00000X
Orthotist
—
—
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
335E00000X
Prosthetic/Orthotic Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0491E
BC/BS/NC
—
05
—
7700578
—
NC
Enumeration date
12/07/2005
Last updated
07/21/2022
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