Provider Demographics
NPI:1912158973
Name:SWEETWATER AESTHETIC CENTER
Entity Type:Organization
Organization Name:SWEETWATER AESTHETIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:C
Authorized Official - Last Name:FONSECA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-213-7865
Mailing Address - Street 1:7389 DAVIE ROAD EXT
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-2421
Mailing Address - Country:US
Mailing Address - Phone:954-443-6681
Mailing Address - Fax:954-443-6683
Practice Address - Street 1:7389 DAVIE ROAD EXT
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-2421
Practice Address - Country:US
Practice Address - Phone:954-443-6681
Practice Address - Fax:954-443-6683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225700000X225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty