=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134615206
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONCIERGE DERMATOLOGY MANAGEMENT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2018
-----------------------------------------------------
Last Update Date | 10/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7100 OAKMONT BLVD STE 101
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76132-3908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-205-3075
-----------------------------------------------------
Fax | 817-641-3355
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7100 OAKMONT BLVD STE 101
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76132-3908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-205-3075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | BRITTANY POPE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-781-3550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WW0000X
-----------------------------------------------------
Taxonomy Name | Wound Care Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number | K0518
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | K0518
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------