Healthcare Provider Details

I. General information

NPI: 1497468862
Provider Name (Legal Business Name): JAMES WILLIAM COSTELLO MS, MSHS, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JAMIE COSTELLO CNGS, FSSRP

II. Dates (important events)

Enumeration Date: 01/02/2023
Last Update Date: 11/16/2024
Certification Date: 11/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5145 S DURANGO DR STE 102
LAS VEGAS NV
89113-0161
US

IV. Provider business mailing address

PO BOX 400787
LAS VEGAS NV
89140-0787
US

V. Phone/Fax

Practice location:
  • Phone: 702-367-7777
  • Fax:
Mailing address:
  • Phone: 702-367-7777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: