Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 5880 | OR |
N | 111NP0017X | Pediatric Chiropractor | 5880 | OR |
NPI | 1619475746 |
---|---|
Provider Name | Dr. Kristin Costanzo |
First Address | Bend, OR 97702-2570 |
Second Address | Bend, OR 97703-2245 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/01/2018 |
Last Update Date | 23/01/2018 |