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
—
—
Other
Enumeration date
11/21/2024
Last updated
11/21/2024
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