Healthcare Provider Details

I. General information

NPI: 1366859324
Provider Name (Legal Business Name): MERCEDES N COSTELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 07/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 E. HUNTINGTON DR
DUARTE CA
91010-2221
US

IV. Provider business mailing address

1721 HUNTINGTON DR APT B
SOUTH PASADENA CA
91030-4833
US

V. Phone/Fax

Practice location:
  • Phone: 626-280-6510
  • Fax: 626-288-1026
Mailing address:
  • Phone: 949-689-0950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: