| Bold Legacy Practice, Llc | |
|
1401 Johnson Ferry Rd Ste 390 Marietta GA 30062-9100 | |
| (470) 795-0047 | |
| Not Available |
| Full Name | Bold Legacy Practice, Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 1401 Johnson Ferry Rd Ste 390, Marietta, Georgia |
| Authorized Official Name and Position | Leia Chatman Dawson (MEDICAL DIRECTOR) |
| Authorized Official Contact | 2059075342 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Bold Legacy Practice, Llc 1117 Eagles Creek Way Nw Acworth GA 30101-4696 Ph: (470) 795-0047 | Bold Legacy Practice, Llc 1401 Johnson Ferry Rd Ste 390 Marietta GA 30062-9100 Ph: (470) 795-0047 |
| NPI Number | 1972212116 |
|---|---|
| Provider Enumeration Date | 11/16/2022 |
| Last Update Date | 01/05/2024 |
| Medicare PECOS PAC ID | 5799140430 |
|---|---|
| Medicare Enrollment ID | O20230502000666 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1972212116 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | (* (Not Available)) | Secondary |
| 261QU0200X | Clinic/center - Urgent Care | (* (Not Available)) | Primary |
| Provider Name | Gregory J Matechak |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1851492672 PECOS PAC ID: 2769456946 Enrollment ID: I20040824000130 |
| Provider Name | Leia Dawson |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1376700989 PECOS PAC ID: 6608054085 Enrollment ID: I20110707000603 |
| Provider Name | Alexis Mitchell |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1356851406 PECOS PAC ID: 3072873512 Enrollment ID: I20210222002312 |
| Provider Name | Stacy Patrick Morgan |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1366122632 PECOS PAC ID: 3173986114 Enrollment ID: I20230824000644 |
| Provider Name | Marjorie L Mcdermott |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1952083321 PECOS PAC ID: 1759744402 Enrollment ID: I20230828003159 |
| Provider Name | Elleni D Kebede |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1124711064 PECOS PAC ID: 8729433305 Enrollment ID: I20231017003163 |
| Provider Name | Asheia Renee' Merritt |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1811797236 PECOS PAC ID: 1052833670 Enrollment ID: I20250324001207 |
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