Graduated: 2022
NPI: 1124711064
Practice Locations (2)
BOLD LEGACY PRACTICE, LLC
1401 JOHNSON FERRY RD, SUITE 390
MARIETTA, GA 300629100
4707950047
BOLD PRIMARY LLC
1401 JOHNSON FERRY RD, SUITE 390B
MARIETTA, GA 300626495
4702501492
Source: CMS National Downloadable File, September 2026.