Provider Demographics
NPI:1619007390
Name:CRAIG COSTELLO DC INC
Entity Type:Organization
Organization Name:CRAIG COSTELLO DC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:814-835-9020
Mailing Address - Street 1:2556 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-4508
Mailing Address - Country:US
Mailing Address - Phone:814-835-9020
Mailing Address - Fax:814-836-9111
Practice Address - Street 1:2556 W 12TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4508
Practice Address - Country:US
Practice Address - Phone:814-835-9020
Practice Address - Fax:814-836-9111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC005032L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA111265Medicare ID - Type Unspecified
PAU35017Medicare UPIN