Provider Demographics
NPI:1235923343
Name:HOGAN, XAVIER COSTOLINO SR
Entity type:Individual
Prefix:
First Name:XAVIER
Middle Name:COSTOLINO
Last Name:HOGAN
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 N CHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-2701
Mailing Address - Country:US
Mailing Address - Phone:313-106-3599
Mailing Address - Fax:
Practice Address - Street 1:115 N CHESTER AVE
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221-2701
Practice Address - Country:US
Practice Address - Phone:313-106-3599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA198320468376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator