Healthcare Provider Details

I. General information

NPI: 1912489741
Provider Name (Legal Business Name): SACRED JOURNEY HOSPICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2018
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 PROFESSIONAL DR STE 165
LAWRENCEVILLE GA
30046-3300
US

IV. Provider business mailing address

805 N WHITTINGTON PKWY
LOUISVILLE KY
40222-7101
US

V. Phone/Fax

Practice location:
  • Phone: 678-583-0717
  • Fax:
Mailing address:
  • Phone: 502-394-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code315D00000X
TaxonomyInpatient Hospice
License Number060-0459-H
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number060-0459-H
License Number StateGA

VIII. Authorized Official

Name: MR. TIMOTHY WHOBREY
Title or Position: PROVIDER ENROLLMENT
Credential:
Phone: 502-630-7249