Healthcare Provider Details

I. General information

NPI: 1275300287
Provider Name (Legal Business Name): BOLD PRIMARY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2023
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 JOHNSON FERRY RD STE 390B
MARIETTA GA
30062-6495
US

IV. Provider business mailing address

1401 JOHNSON FERRY RD STE 390B
MARIETTA GA
30062-6495
US

V. Phone/Fax

Practice location:
  • Phone: 470-250-1492
  • Fax: 470-235-7311
Mailing address:
  • Phone: 470-250-1492
  • Fax: 470-235-7311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LEIA DAWSON
Title or Position: MEDICAL DIRECTOR/ EXECUTIVE OFFICER
Credential: DO
Phone: 470-250-1492