MEDICARE: CONCIERGE PROFESSIONAL PHLEBOTOMY SERVICE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	202K00000X	Phlebology Physician

General Provider Information

NPI Number	:	1861037699
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONCIERGE PROFESSIONAL PHLEBOTOMY SERVICE, LLC

Provider Business Mailing Address
First Line	:	6281 FISKE RD
Second Line	:
City	:	BARTLETT
State	:	TN
Zip	:	38135-1107
Country	:	US
Telephone Number	:	901-218-6769
Fax Number	:

Provider Business Practice Location Address
First Line	:	2670 UNION AVENUE EXT STE 1216
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38112-4422
Country	:	US
Telephone Number	:	901-218-6769
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. JENNIFER C RANDLE
Credential	:	MLS, MSHA
Telephone Number	:	901-218-6769

Provider Enumeration Date	:	11/15/2019
Last Update Date	:	11/15/2019

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