Provider Demographics
NPI:1073871547
Name:COSTANTINO CHIROPRACTIC CORPORATION
Entity Type:Organization
Organization Name:COSTANTINO CHIROPRACTIC CORPORATION
Other - Org Name:HEALTH SOURCE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:COSTANTINO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-798-3227
Mailing Address - Street 1:1100 PACIFIC COAST HWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-3951
Mailing Address - Country:US
Mailing Address - Phone:310-798-3227
Mailing Address - Fax:310-798-3229
Practice Address - Street 1:1100 PACIFIC COAST HWY
Practice Address - Street 2:SUITE A
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-3951
Practice Address - Country:US
Practice Address - Phone:310-798-3227
Practice Address - Fax:310-798-3229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21279111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC21279Medicare UPIN