1578139218 NPI number — SWEETWATER COLLECTIVE LLC

Table of content: (NPI 1578139218)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578139218 NPI number — SWEETWATER COLLECTIVE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SWEETWATER COLLECTIVE LLC
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:
1578139218
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 DEVANT ST STE 1001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30214-2719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-310-3182
Provider Business Mailing Address Fax Number:
678-788-6690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 DEVANT ST STE 1001
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-2719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-310-3182
Provider Business Practice Location Address Fax Number:
678-788-6690
Provider Enumeration Date:
06/02/2021

Additional Information

Authorized Official

Authorized Official Last Name:
JACALA
Authorized Official First Name:
BARBARA JOIE
Authorized Official Middle Name:
V
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
678-310-3182

Provider Taxonomy Codes

  • Taxonomy code: 171100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 521 . This is a "ACUPUNCTURIST" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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