Provider Demographics
NPI:1558456202
Name:COSTELLO, TAMMY LYNNE (DC)
Entity Type:Individual
Prefix:DR
First Name:TAMMY
Middle Name:LYNNE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 ROBERT GRISSOM PKWY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579
Mailing Address - Country:US
Mailing Address - Phone:843-839-5588
Mailing Address - Fax:843-839-5591
Practice Address - Street 1:1151 ROBERT GRISSOM PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5664
Practice Address - Country:US
Practice Address - Phone:843-839-5588
Practice Address - Fax:843-839-5591
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC2755111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCU787838630Medicare ID - Type Unspecified