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General NPI Number Information
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NPI Number | 1942885611
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Entity Type | Organization
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Legal Business Name | CONCIERGE CLINIC
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Dates
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Enumeration Date | 03/15/2021
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Last Update Date | 03/30/2021
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Provider Practice Location Address
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Address Line | 152 STATION DR
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City | LEESBURG
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State | GA
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Zip | 31763-5631
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Country | US
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Telephone | 229-814-8426
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Fax |
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Provider Business Mailing Address
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Address Line | 152 STATION DR
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City | LEESBURG
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State | GA
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Zip | 31763-5631
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Country | US
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Telephone | 229-814-8426
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. AUDREA VAUGHAN
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Credential | DO
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Telephone | 954-825-7615
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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