Provider Demographics
NPI:1982996567
Name:MB COSTELLO ENTERPRISES LLC
Entity type:Organization
Organization Name:MB COSTELLO ENTERPRISES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FRANCHISEE
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:404-354-3111
Mailing Address - Street 1:1501 LAKELAND DR
Mailing Address - Street 2:SUITE 251
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4834
Mailing Address - Country:US
Mailing Address - Phone:601-320-8000
Mailing Address - Fax:601-320-8001
Practice Address - Street 1:1501 LAKELAND DR STE 251
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4848
Practice Address - Country:US
Practice Address - Phone:601-321-8000
Practice Address - Fax:601-321-8001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-13
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty