Bold Legacy Practice, LLC

Primary specialty

Clinic/CenterTaxonomy code 261Q00000X

Legal business name

BOLD LEGACY PRACTICE, LLC

Practice address

1401 Johnson Ferry Rd Ste 390
Marietta, GA 30062-9100

Phone

(470) 795-0047

NPI assigned

Jan 10, 2023

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Leia M Dawson, DONPI 1376700989

Title

Medical Director

Phone

(470) 795-0047

Specialties & licenses 1

Addresses

Tax ID family

American Family Care2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Bold Legacy Practice, LLC

  dba American Family Care

  • Urgent Care Clinic/Center
  • Marietta, GA
  • NPI 1972212116
  NPD tax ID

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Leia M Dawson, D.O.

  • Family Medicine Physician
  • Marietta, GA
  • NPI 1376700989
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1673308800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1703721600000",
    "number": "1962116392",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1117 EAGLES CREEK WAY NW",
            "city": "ACWORTH",
            "state": "GA",
            "postal_code": "301014696",
            "telephone_number": "205-907-5342"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1401 JOHNSON FERRY RD STE 390",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300629100",
            "telephone_number": "470-795-0047"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BOLD LEGACY PRACTICE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-01-10",
        "last_updated": "2023-12-28",
        "certification_date": "2023-12-28",
        "status": "A",
        "authorized_official_last_name": "DAWSON",
        "authorized_official_first_name": "LEIA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "470-795-0047",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Joann Bogdal, RBT
• Tammy L. Bogdan, MS, RD, LD, CDCES
• Alina Nicol Boger, CNM
• Laura Bohanon, RBT
• Mac Kenzie Hunter Bohns
• Bold Legacy Practice, LLC (American Family Care)
• Bold Primary LLC (American Family Care)
• Carol Bayless Bolden, D.M.D.
• Bolt Eye Group-East Cobb LLC
• Karen Bolton

• Clinic/Center in Marietta, GA
• Providers in Marietta, GA by specialty
• Clinic/Center in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 28, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.