Provider Demographics
NPI:1942885611
Name:CONCIERGE CLINIC
Entity Type:Organization
Organization Name:CONCIERGE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-825-7615
Mailing Address - Street 1:152 STATION DR
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-5631
Mailing Address - Country:US
Mailing Address - Phone:229-814-8426
Mailing Address - Fax:
Practice Address - Street 1:152 STATION DR
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-5631
Practice Address - Country:US
Practice Address - Phone:229-814-8426
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-15
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty