Provider Demographics
NPI:1366220758
Name:CONCIERGE MEDICAL LAB
Entity type:Organization
Organization Name:CONCIERGE MEDICAL LAB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:DOCTOR-GREENWADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-722-4988
Mailing Address - Street 1:PO BOX 23328
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29224-3328
Mailing Address - Country:US
Mailing Address - Phone:803-722-4988
Mailing Address - Fax:803-656-8135
Practice Address - Street 1:110 WILDEWOOD PARK DR STE A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-4301
Practice Address - Country:US
Practice Address - Phone:803-722-9888
Practice Address - Fax:803-656-8135
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONCIERGE MEDICAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-18
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207RI0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical & Laboratory ImmunologyGroup - Multi-Specialty
No246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical LaboratoryGroup - Multi-Specialty