Provider Demographics
NPI:1124718366
Name:EXCELLENCE CONCIERGE MEDICINE LLC
Entity type:Organization
Organization Name:EXCELLENCE CONCIERGE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:901-832-6805
Mailing Address - Street 1:6515 GOODMAN RD
Mailing Address - Street 2:SUITE 4 BOX 298
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654
Mailing Address - Country:US
Mailing Address - Phone:901-832-6805
Mailing Address - Fax:
Practice Address - Street 1:7712 KERI CV
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-5049
Practice Address - Country:US
Practice Address - Phone:901-832-6805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Single Specialty