1831075423 NPI number — SACRED SEASONS LIFE CARE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831075423 NPI number — SACRED SEASONS LIFE CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SACRED SEASONS LIFE CARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1831075423
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
470 DACULA ROAD PO BOX 1424
Provider Second Line Business Mailing Address:
715 BAILEY WOODS ROAD DACULA, GA 30019
Provider Business Mailing Address City Name:
DACULA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30019-3001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-923-3973
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
715 BAILEY WOODS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DACULA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30019-1233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-923-3973
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/12/2025

Additional Information

Authorized Official

Authorized Official Last Name:
HOUSTON
Authorized Official First Name:
PEAESHA
Authorized Official Middle Name:
LYNETTE
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
678-923-3973

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , registered in the state of NULL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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