Provider Demographics
NPI:1598235632
Name:SAGE LAKE HOME CARE, LLC
Entity Type:Organization
Organization Name:SAGE LAKE HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR OF ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:CHANONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-506-1880
Mailing Address - Street 1:2710 RATBY LN NE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-1875
Mailing Address - Country:US
Mailing Address - Phone:678-506-1880
Mailing Address - Fax:
Practice Address - Street 1:1775 PARKER RD SE STE 210
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-6654
Practice Address - Country:US
Practice Address - Phone:678-506-1880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-02
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty