Healthcare Provider Details

I. General information

NPI: 1790201044
Provider Name (Legal Business Name): SWEETWATER LIFE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 MCGILL PARK AVE NE
ATLANTA GA
30312-4221
US

IV. Provider business mailing address

1117 MCGILL PARK AVE NE
ATLANTA GA
30312-4221
US

V. Phone/Fax

Practice location:
  • Phone: 404-734-8853
  • Fax:
Mailing address:
  • Phone: 404-734-8853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License NumberMT008978
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT008978
License Number StateGA

VIII. Authorized Official

Name: LEKEISHA MARQUIS JONES
Title or Position: OWNER
Credential: LMT
Phone: 404-734-8853