Healthcare Provider Details

I. General information

NPI: 1447618707
Provider Name (Legal Business Name): CONCIERGE MEDICAL MGMT GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2016
Last Update Date: 05/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 OLD ROSWELL RD STE 117
ROSWELL GA
30076
US

IV. Provider business mailing address

760 OLD ROSWELL RD STE 117
ROSWELL GA
30076-8685
US

V. Phone/Fax

Practice location:
  • Phone: 800-704-8875
  • Fax: 888-816-7047
Mailing address:
  • Phone: 800-704-8875
  • Fax: 888-840-1265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number StateNULL

VIII. Authorized Official

Name: NANCY BONNER
Title or Position: PRESIDENT
Credential:
Phone: 678-500-9568