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General NPI Number Information
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NPI Number | 1578139218
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Entity Type | Organization
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Legal Business Name | SWEETWATER COLLECTIVE LLC
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Dates
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Enumeration Date | 06/02/2021
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Last Update Date | 02/08/2024
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Provider Practice Location Address
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Address Line | 101 DEVANT ST STE 1001
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-2719
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Country | US
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Telephone | 678-310-3182
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Fax | 678-788-6690
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Provider Business Mailing Address
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Address Line | 101 DEVANT ST STE 1001
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-2719
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Country | US
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Telephone | 678-310-3182
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Fax | 678-788-6690
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Authorized Official
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Title or Position | CEO
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Name | BARBARA JOIE V JACALA
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Credential | LAC AEMP
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Telephone | 678-310-3182
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number |
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License Number State |
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