Provider Demographics
NPI:1619073228
Name:COSTELLO CLINIC, P.A.
Entity Type:Organization
Organization Name:COSTELLO CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-221-7006
Mailing Address - Street 1:131 DEGAN AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-3622
Mailing Address - Country:US
Mailing Address - Phone:972-221-7006
Mailing Address - Fax:972-353-5081
Practice Address - Street 1:131 DEGAN AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-3622
Practice Address - Country:US
Practice Address - Phone:972-221-7006
Practice Address - Fax:972-353-5081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health