=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275286247
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONCIERGE PERSONAL TRAINING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2022
-----------------------------------------------------
Last Update Date | 02/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 239 TAMARACK AVE APT B
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92008-4087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-284-8004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 239 TAMARACK AVE APT B
-----------------------------------------------------
City | CARLSBAD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92008-4087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-449-6954
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RACHAEL DIANE ROSS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 858-449-6954
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------