Provider Demographics
NPI:1760649214
Name:ERIC R NISENSON
Entity Type:Organization
Organization Name:ERIC R NISENSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:R
Authorized Official - Last Name:NISENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-362-9959
Mailing Address - Street 1:PO BOX 845
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05254-0845
Mailing Address - Country:US
Mailing Address - Phone:802-362-9959
Mailing Address - Fax:
Practice Address - Street 1:7252 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MANCHESTER CENTER
Practice Address - State:VT
Practice Address - Zip Code:05255
Practice Address - Country:US
Practice Address - Phone:802-362-9959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0560000179332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1012914OtherMEDICAID DME
VT0946670002Medicare NSC