Provider Demographics
NPI:1346791878
Name:LEGG, FRED VAUGHAN III
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:VAUGHAN
Last Name:LEGG
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 BLACK BEAR RIDGE RD
Mailing Address - Street 2:BLACK BEAR TREATMENT CENTER
Mailing Address - City:SAUTEE
Mailing Address - State:GA
Mailing Address - Zip Code:30571
Mailing Address - Country:US
Mailing Address - Phone:470-539-6905
Mailing Address - Fax:706-219-3078
Practice Address - Street 1:310 BLACK BEAR RIDGE RD
Practice Address - Street 2:BLACK BEAR TREATMENT CENTER
Practice Address - City:SAUTEE
Practice Address - State:GA
Practice Address - Zip Code:30571
Practice Address - Country:US
Practice Address - Phone:470-539-6905
Practice Address - Fax:706-219-3078
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN117118363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily