Healthcare Provider Details

I. General information

NPI: 1649398207
Provider Name (Legal Business Name): JOAN V. EWIG RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13111 N PORT WASHINGTON RD COLUMBIA-ST. MARY'S
MEQUON WI
53097-2416
US

IV. Provider business mailing address

13111 N PORT WASHINGTON RD COLUMBIA-ST. MARY'S
MEQUON WI
53097-2416
US

V. Phone/Fax

Practice location:
  • Phone: 262-243-7564
  • Fax: 262-243-7318
Mailing address:
  • Phone: 262-243-7564
  • Fax: 262-243-7318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: