1164210266 NPI number — CONCIERGE DIAGNOSTIC SERVICES LLC

Table of content: (NPI 1164210266)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164210266 NPI number — CONCIERGE DIAGNOSTIC SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONCIERGE DIAGNOSTIC SERVICES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164210266
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1220 2ND AVE STE 106
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31901-1111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
470-241-6604
Provider Business Mailing Address Fax Number:
706-940-4415

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1220 2ND AVE STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31901-1114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
470-241-6604
Provider Business Practice Location Address Fax Number:
706-940-4415
Provider Enumeration Date:
04/28/2025

Additional Information

Authorized Official

Authorized Official Last Name:
WASHINGTON, ED.D.
Authorized Official First Name:
CORINTHIANS
Authorized Official Middle Name:
DEQUINDRAE
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
470-241-6604

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0104X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 246RP1900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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