Provider Demographics
NPI:1972212116
Name:BOLD LEGACY PRACTICE, LLC
Entity type:Organization
Organization Name:BOLD LEGACY PRACTICE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LEIA
Authorized Official - Middle Name:CHATMAN
Authorized Official - Last Name:DAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:205-907-5342
Mailing Address - Street 1:1117 EAGLES CREEK WAY NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-4696
Mailing Address - Country:US
Mailing Address - Phone:470-795-0047
Mailing Address - Fax:
Practice Address - Street 1:1401 JOHNSON FERRY RD STE 390
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-9100
Practice Address - Country:US
Practice Address - Phone:470-795-0047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-16
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center