Provider Demographics
NPI:1578139218
Name:SWEETWATER COLLECTIVE LLC
Entity Type:Organization
Organization Name:SWEETWATER COLLECTIVE LLC
Other - Org Name:FAYETTE ACUPUNCTURE & INTEGRATIVE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA JOIE
Authorized Official - Middle Name:V
Authorized Official - Last Name:JACALA
Authorized Official - Suffix:
Authorized Official - Credentials:LAC AEMP
Authorized Official - Phone:678-310-3182
Mailing Address - Street 1:101 DEVANT ST STE 1001
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-2719
Mailing Address - Country:US
Mailing Address - Phone:678-310-3182
Mailing Address - Fax:678-788-6690
Practice Address - Street 1:101 DEVANT ST STE 1001
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2719
Practice Address - Country:US
Practice Address - Phone:678-310-3182
Practice Address - Fax:678-788-6690
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SWEETWATER COLLECTIVE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-02
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA521OtherACUPUNCTURIST