Provider Demographics
NPI:1063965291
Name:EGGERT, SHARON I
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:EGGERT
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13681 E SHAW AVE
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:CA
Mailing Address - Zip Code:93657-9208
Mailing Address - Country:US
Mailing Address - Phone:559-270-7703
Mailing Address - Fax:
Practice Address - Street 1:13681 E SHAW AVE
Practice Address - Street 2:
Practice Address - City:SANGER
Practice Address - State:CA
Practice Address - Zip Code:93657-9208
Practice Address - Country:US
Practice Address - Phone:559-270-7703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-23
Last Update Date:2016-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA04000X324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility