MEDICARE: CRAIG C COSTELLO D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	DC005032L	PA

General Provider Information

NPI Number	:	1316019698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRAIG C COSTELLO D.C.

Provider Business Mailing Address
First Line	:	2556 W 12TH ST
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16505-4508
Country	:	US
Telephone Number	:	814-835-9020
Fax Number	:	814-836-9111

Provider Business Practice Location Address
First Line	:	2556 W 12TH ST
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16505-4508
Country	:	US
Telephone Number	:	814-835-9020
Fax Number	:	814-836-9111

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	07/08/2007

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