Provider Demographics
NPI:1891251898
Name:PIVOT CONCIERGE HEALTH, LLC
Entity Type:Organization
Organization Name:PIVOT CONCIERGE HEALTH, LLC
Other - Org Name:TOTAL MALE WELLNESS, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-350-1024
Mailing Address - Street 1:2801 S 88TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-3056
Mailing Address - Country:US
Mailing Address - Phone:402-885-8125
Mailing Address - Fax:402-625-0578
Practice Address - Street 1:2801 S 88TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-3056
Practice Address - Country:US
Practice Address - Phone:402-885-8125
Practice Address - Fax:402-625-0578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-14
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026770100Medicaid