=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518667484
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONCIERGE ORTHOPEDICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2023
-----------------------------------------------------
Last Update Date | 03/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 459 STONE VIEW TRL
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78737-2849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-723-5068
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 459 STONE VIEW TRL
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78737-2849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-723-5068
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND CEO
-----------------------------------------------------
Name | DR. KELLI CHANDLER
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 870-723-5068
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------