NPIMap

Organization Active NPI

Bold Legacy Practice, LLC

Doing business as American Family Care

  • Urgent Care Clinic/Center
  • Marietta, GA
National Provider Identifier
1972212116
Registry record updated Jan 5, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Urgent Care Clinic/CenterTaxonomy code 261QU0200X
Legal business name
BOLD LEGACY PRACTICE, LLC
Doing business as
American Family Care
Bold Legacy Management, LLC
Quadrivium Health LLC
Practice address
1401 Johnson Ferry Rd Ste 390
Marietta, GA 30062-9100
Phone
(470) 795-0047
NPI assigned
Nov 16, 2022
Last updated
Jan 5, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 5, 2024

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

Authorized official

Name
Dr. Leia Chatman Dawson, DO
Title
Medical Director
Phone
(205) 907-5342

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X
Urgent Care Clinic/Center 261QU0200X Primary

Addresses

Primary practice location

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

Mailing address

1117 Eagles Creek Way NW
Acworth, GA 30101-4696
Phone (470) 795-0047

Other names 3

  • American Family Care Doing business as
  • Bold Legacy Management, LLC Doing business as
  • Quadrivium Health LLC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230502000666 GA Part B Supplier - Clinic/Group Practice 5799140430 Receives reassigned benefits from 7 practitioners
Practice locations: Marietta, GA

National Provider Directory

National Provider Directory
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.

Locations

1401 Johnson Ferry Rd
Ste 390
Marietta, GA 30062
Phone (470) 250-1492

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1668556800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1704412800000",
    "number": "1972212116",
    "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": "470-795-0047"
        },
        {
            "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": "2022-11-16",
        "last_updated": "2024-01-05",
        "certification_date": "2024-01-05",
        "status": "A",
        "authorized_official_last_name": "DAWSON",
        "authorized_official_first_name": "LEIA",
        "authorized_official_middle_name": "CHATMAN",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "205-907-5342",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QU0200X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Urgent Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "American Family Care",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Bold Legacy Management, LLC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Quadrivium Health LLC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Quadrivium Health LLC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Marietta, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 5, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.