Provider Demographics
NPI:1184974651
Name:COSTELLO, BRUCE (DC)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:COSTELLO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 RIVERBEND DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-4110
Mailing Address - Country:US
Mailing Address - Phone:404-354-3111
Mailing Address - Fax:
Practice Address - Street 1:2365 WALL ST SE
Practice Address - Street 2:SUITE 100
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2197
Practice Address - Country:US
Practice Address - Phone:770-922-8187
Practice Address - Fax:770-922-9107
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR002554111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation