Healthcare Provider Details

I. General information

NPI: 1619110269
Provider Name (Legal Business Name): EQUI-MED CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2009
Last Update Date: 04/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1252 N SIERRA BONITA AVE
PASADENA CA
91104-3147
US

IV. Provider business mailing address

1252 N SIERRA BONITA AVE
PASADENA CA
91104-3147
US

V. Phone/Fax

Practice location:
  • Phone: 805-217-4998
  • Fax:
Mailing address:
  • Phone: 805-217-4998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA43746
License Number StateCA

VIII. Authorized Official

Name: BRIAN JOHN COSTELLO
Title or Position: PRESIDENT
Credential:
Phone: 805-217-4998