1346791878 NPI number — MR. FRED VAUGHAN LEGG III

Table of content: MR. FRED VAUGHAN LEGG III (NPI 1346791878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346791878 NPI number — MR. FRED VAUGHAN LEGG III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEGG
Provider First Name:
FRED
Provider Middle Name:
VAUGHAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346791878
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 BLACK BEAR RIDGE RD
Provider Second Line Business Mailing Address:
BLACK BEAR TREATMENT CENTER
Provider Business Mailing Address City Name:
SAUTEE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
470-539-6905
Provider Business Mailing Address Fax Number:
706-219-3078

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 BLACK BEAR RIDGE RD
Provider Second Line Business Practice Location Address:
BLACK BEAR TREATMENT CENTER
Provider Business Practice Location Address City Name:
SAUTEE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
470-539-6905
Provider Business Practice Location Address Fax Number:
706-219-3078
Provider Enumeration Date:
10/19/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  RN117118 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)