Healthcare Provider Details

I. General information

NPI: 1114562014
Provider Name (Legal Business Name): DMMD CONCIERGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

947 EASTERN PKWY
LOUISVILLE KY
40217-1573
US

IV. Provider business mailing address

3202 THOUSAND OAKS DR
LOUISVILLE KY
40205-2703
US

V. Phone/Fax

Practice location:
  • Phone: 502-361-8801
  • Fax: 502-361-8821
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DOUG MATTINGLY
Title or Position: OWNER
Credential: MD
Phone: 502-361-8801