MEDICARE: CONCIERGE AESTHETICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207LP2900X	Pain Medicine (Anesthesiology) Physician	ME124453	FL

General Provider Information

NPI Number	:	1619350964
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONCIERGE AESTHETICS, LLC

Provider Business Mailing Address
First Line	:	511 SE 5TH AVE
Second Line	:	SUITE 1901
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-2984
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	511 SE 5TH AVE
Second Line	:	SUITE 1901
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-2984
Country	:	US
Telephone Number	:	847-894-1127
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DANIEL BORMAN
Credential	:	M.D.
Telephone Number	:	847-894-1127

Provider Enumeration Date	:	07/06/2015
Last Update Date	:	07/06/2015

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