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General NPI Number Information
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NPI Number | 1598235632
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Entity Type | Organization
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Legal Business Name | SAGE LAKE HOME CARE, LLC
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Dates
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Enumeration Date | 12/02/2018
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Last Update Date | 08/18/2021
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Provider Practice Location Address
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Address Line | 1775 PARKER RD SE STE 210
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City | CONYERS
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State | GA
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Zip | 30094-6654
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Country | US
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Telephone | 678-506-1880
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Fax |
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Provider Business Mailing Address
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Address Line | 2710 RATBY LN NE
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City | CONYERS
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State | GA
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Zip | 30013-1875
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Country | US
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Telephone | 678-506-1880
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Fax |
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Authorized Official
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Title or Position | OWNER/DIRECTOR OF ADMINISTRATION
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Name | CHANONNE THOMAS
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Credential |
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Telephone | 678-506-1880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 372600000X
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Taxonomy Name | Adult Companion
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3747P1801X
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Taxonomy Name | Personal Care Attendant
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License Number |
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License Number State |
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