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General NPI Number Information
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NPI Number | 1366859324
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Entity Type | Individual
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Provider Name | MERCEDES N COSTELLO
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Gender | Female
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Dates
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Enumeration Date | 07/22/2014
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Last Update Date | 07/28/2014
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Provider Practice Location Address
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Address Line | 2502 E. HUNTINGTON DR
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City | DUARTE
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State | CA
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Zip | 91010-2221
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Country | US
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Telephone | 626-280-6510
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Fax | 626-288-1026
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Provider Business Mailing Address
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Address Line | 1721 HUNTINGTON DR APT B
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City | SOUTH PASADENA
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State | CA
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Zip | 91030-4833
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Country | US
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Telephone | 949-689-0950
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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