Provider Demographics
NPI:1619475746
Name:COSTANZO, KRISTIN (DC)
Entity Type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:
Last Name:COSTANZO
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 1:20036 BADGER RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2570
Mailing Address - Country:US
Mailing Address - Phone:303-656-5752
Mailing Address - Fax:
Practice Address - Street 1:1004 NW MILWAUKEE AVE STE 200
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2245
Practice Address - Country:US
Practice Address - Phone:541-312-9794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5880111NP0017X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor