Organization
CUSTOM BRACE SHOP INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. FAKHRY WILSON AZER P.T. (PRESIDENT /OWNER)
(309) 344-3400
Entity
Organization
Contact information
Practice address
872 W DAYTON ST, GALESBURG, IL 61401-1503
(309) 344-5330
(309) 344-5040
Mailing address
872 W DAYTON ST, GALESBURG, IL 61401-1503
(309) 344-5330
(309) 344-5040
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
30404878
CERTIFICATE OF REGISTRATI
IL
Enumeration date
07/19/2006
Last updated
07/11/2008
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