Provider Demographics
NPI:1609263615
Name:CONCIERGE MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:CONCIERGE MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:NISSLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-412-4562
Mailing Address - Street 1:9777 S YOSEMITE ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-3191
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9777 S YOSEMITE ST
Practice Address - Street 2:SUITE 110
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-3191
Practice Address - Country:US
Practice Address - Phone:720-412-4562
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty