Provider Demographics
NPI:1780946863
Name:ANDREA MARIE EWERT
Entity type:Organization
Organization Name:ANDREA MARIE EWERT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:EWERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-523-0202
Mailing Address - Street 1:PO BOX 578173
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-8173
Mailing Address - Country:US
Mailing Address - Phone:209-523-0202
Mailing Address - Fax:888-499-0202
Practice Address - Street 1:4049 N FREEWAY BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-1253
Practice Address - Country:US
Practice Address - Phone:916-920-0202
Practice Address - Fax:877-744-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6086960003Medicare NSC