Healthcare Provider Details

I. General information

NPI: 1144635087
Provider Name (Legal Business Name): ANN R COSTELLO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 01/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 N AURORA ST SUITE 2
ITHACA NY
14850-4345
US

IV. Provider business mailing address

9276 SCRANTON RD SUITE 100
SAN DIEGO CA
92121-7701
US

V. Phone/Fax

Practice location:
  • Phone: 607-273-2811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number149866
License Number StateNY

VIII. Authorized Official

Name: SCOTT PETERSON
Title or Position: CFO
Credential:
Phone: 858-625-2990