Provider Demographics
NPI:1164035606
Name:IDAHOR, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:IDAHOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 TAMARACK DR
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-5013
Mailing Address - Country:US
Mailing Address - Phone:781-223-1671
Mailing Address - Fax:
Practice Address - Street 1:111 TAMARACK DR
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-5013
Practice Address - Country:US
Practice Address - Phone:781-223-1671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN91073164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse