Basic Information
| Provider Information | |||||||||
| NPI: | 1306919683 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SACRED JOURNEY HOSPICE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SACRED JOURNEY HOSPICE, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 N WHITTINGTON PKWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402227101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023942100 | ||||||||
| FaxNumber: | 5023942159 | ||||||||
| Practice Location | |||||||||
| Address1: | 138 PEACH DR | ||||||||
| Address2: | |||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785830717 | ||||||||
| FaxNumber: | 6785830712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | WHOBREY | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 5026307249 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315D00000X | 075176H | GA | N | Nursing & Custodial Care Facilities | Hospice, Inpatient | 251G00000X | 075176H | GA | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 054652053A | 05 | GA | MEDICAID |