Provider Demographics
NPI:1508461070
Name:LEGACY PRIMARY CARE AND WELLNESS
Entity Type:Organization
Organization Name:LEGACY PRIMARY CARE AND WELLNESS
Other - Org Name:LEGACY PRIMARY CARE AND WELLNESS LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:STRONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-703-8465
Mailing Address - Street 1:195 UPPER RIVERDALE RD SW STE B
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2518
Mailing Address - Country:US
Mailing Address - Phone:770-703-8465
Mailing Address - Fax:770-629-2392
Practice Address - Street 1:195 UPPER RIVERDALE RD SW STE B
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2518
Practice Address - Country:US
Practice Address - Phone:770-703-8465
Practice Address - Fax:770-629-2392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-02
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care