Provider Demographics
NPI:1003630427
Name:I AM LEGACY PTCA INC.
Entity type:Organization
Organization Name:I AM LEGACY PTCA INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EVANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-465-1391
Mailing Address - Street 1:514 W OGLETHORPE BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1479
Mailing Address - Country:US
Mailing Address - Phone:404-465-1391
Mailing Address - Fax:
Practice Address - Street 1:514 W OGLETHORPE BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1478
Practice Address - Country:US
Practice Address - Phone:404-465-1391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
No251B00000XAgenciesCase Management
No251J00000XAgenciesNursing Care
No251K00000XAgenciesPublic Health or Welfare
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency