Healthcare Provider Details

I. General information

NPI: 1124380860
Provider Name (Legal Business Name): MRS. MICHELE COSTANZO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10074 STATION RD
COLUMBIA STATION OH
44028-9594
US

IV. Provider business mailing address

10074 STATION RD
COLUMBIA STATION OH
44028-9594
US

V. Phone/Fax

Practice location:
  • Phone: 440-236-3937
  • Fax:
Mailing address:
  • Phone: 440-236-3937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number4133-S
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: