Provider Demographics
NPI:1790201044
Name:SWEETWATER LIFE, LLC
Entity Type:Organization
Organization Name:SWEETWATER LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEKEISHA
Authorized Official - Middle Name:MARQUIS
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:404-734-8853
Mailing Address - Street 1:1117 MCGILL PARK AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-4221
Mailing Address - Country:US
Mailing Address - Phone:404-734-8853
Mailing Address - Fax:
Practice Address - Street 1:1117 MCGILL PARK AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-4221
Practice Address - Country:US
Practice Address - Phone:404-734-8853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT008978173C00000X, 225700000X
GA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
No173C00000XOther Service ProvidersReflexologistGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAMT008978OtherMASSAGE THERAPY