MEDICARE: EQUI-MED CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	A43746	CA

General Provider Information

NPI Number	:	1619110269
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EQUI-MED CORP

Provider Business Mailing Address
First Line	:	1252 N SIERRA BONITA AVE
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91104-3147
Country	:	US
Telephone Number	:	805-217-4998
Fax Number	:

Provider Business Practice Location Address
First Line	:	1252 N SIERRA BONITA AVE
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91104-3147
Country	:	US
Telephone Number	:	805-217-4998
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRIAN JOHN COSTELLO
Credential	:
Telephone Number	:	805-217-4998

Provider Enumeration Date	:	04/13/2009
Last Update Date	:	04/13/2009

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Directions to “EQUI-MED CORP ” Practice Location

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