MEDICARE: JACKOLINE B EWIG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1861766990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKOLINE B EWIG

Provider Business Mailing Address
First Line	:	8040 GREENBUSH DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-3768
Country	:	US
Telephone Number	:	702-247-9534
Fax Number	:

Provider Business Practice Location Address
First Line	:	8040 GREENBUSH DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-3768
Country	:	US
Telephone Number	:	702-247-9534
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2012
Last Update Date	:	03/07/2012

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