Provider Demographics
NPI:1790469781
Name:MORA, EDDER GEOVANNY
Entity Type:Individual
Prefix:
First Name:EDDER
Middle Name:GEOVANNY
Last Name:MORA
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 1:87 PHILLIPS ST
Mailing Address - Street 2:
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-4311
Mailing Address - Country:US
Mailing Address - Phone:978-835-5358
Mailing Address - Fax:
Practice Address - Street 1:360 MERRIMACK ST STE 9
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-1764
Practice Address - Country:US
Practice Address - Phone:978-655-6652
Practice Address - Fax:833-963-2112
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN101085164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse