Provider Demographics
NPI:1366218414
Name:COSTA CLINIC PLLC
Entity type:Organization
Organization Name:COSTA CLINIC PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PRIYANKA
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTA HENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-625-0574
Mailing Address - Street 1:1628 E SOUTHERN AVE STE 9803
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-5782
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3811 E BELL RD STE 106
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2158
Practice Address - Country:US
Practice Address - Phone:602-443-1085
Practice Address - Fax:602-443-1086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-29
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty