Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0400X | Rehabilitation Chiropractor | CHIR002554 | GA |
NPI | 1184974651 |
---|---|
Provider Name | Bruce Costello |
First Address | Mcdonough, GA 30252-4110 |
Second Address | Conyers, GA 30013-2197 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/09/2012 |
Last Update Date | 12/09/2012 |