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General NPI Number Information
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NPI Number | 1619110269
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Entity Type | Organization
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Legal Business Name | EQUI-MED CORP
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Dates
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Enumeration Date | 04/13/2009
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Last Update Date | 04/13/2009
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Provider Practice Location Address
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Address Line | 1252 N SIERRA BONITA AVE
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City | PASADENA
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State | CA
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Zip | 91104-3147
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Country | US
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Telephone | 805-217-4998
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Fax |
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Provider Business Mailing Address
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Address Line | 1252 N SIERRA BONITA AVE
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City | PASADENA
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State | CA
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Zip | 91104-3147
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Country | US
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Telephone | 805-217-4998
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRIAN JOHN COSTELLO
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Credential |
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Telephone | 805-217-4998
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | A43746
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License Number State | CA
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