NPIMap

Organization Active NPI

Sacred Waters, LLC

  • Other Technician
  • Fayetteville, GA
National Provider Identifier
1033546049
Registry record updated Oct 4, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Other TechnicianTaxonomy code 247200000X
Legal business name
SACRED WATERS, LLC
Doing business as
Sacred Waters Wellness
Practice address
500 Lanier Ave W Ste 701
Fayetteville, GA 30214-7643
Phone
(770) 460-9122
NPI assigned
Oct 4, 2013
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 4, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kelly JeffersonNPI 1811254055
Title
Managing Directo
Phone
(770) 460-9122

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Other TechnicianGroup: 193200000X MULTI-SPECIALTY GROUP 247200000X GA Primary

Addresses

Primary practice location

500 Lanier Ave W Ste 701
Fayetteville, GA 30214-7643

Mailing address

500 Lanier Ave W Ste 701
Fayetteville, GA 30214-7643
Phone (770) 460-9122

Other names 1

  • Sacred Waters Wellness Doing business as

National Provider Directory

National Provider Directory

Locations

500 Lanier Ave W
Ste 701
Fayetteville, GA 30214
Phone (770) 460-9122

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1380844800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1380844800000",
    "number": "1033546049",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "500 LANIER AVE W STE 701",
            "city": "FAYETTEVILLE",
            "state": "GA",
            "postal_code": "302147643",
            "telephone_number": "770-460-9122"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "500 LANIER AVE W STE 701",
            "city": "FAYETTEVILLE",
            "state": "GA",
            "postal_code": "302147643",
            "telephone_number": "770-460-9122"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SACRED WATERS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-10-04",
        "last_updated": "2013-10-04",
        "status": "A",
        "authorized_official_last_name": "JEFFERSON",
        "authorized_official_first_name": "KELLY",
        "authorized_official_title_or_position": "MANAGING DIRECTO",
        "authorized_official_telephone_number": "770-460-9122"
    },
    "taxonomies": [
        {
            "code": "247200000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Technician, Other",
            "state": "GA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Sacred Waters Wellness",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fayetteville, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 4, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.