MEDICARE: DOMINIQUE KWAINE IDAHOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	08933451	TX

General Provider Information

NPI Number	:	1053780254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE KWAINE IDAHOR

Provider Business Mailing Address
First Line	:	5813 LINCOLN MEADOWS CT
Second Line	:	409
City	:	FORT WORTH
State	:	TX
Zip	:	76112-1451
Country	:	US
Telephone Number	:	817-986-6999
Fax Number	:

Provider Business Practice Location Address
First Line	:	5813 LINCOLN MEADOWS CT
Second Line	:	409
City	:	FORT WORTH
State	:	TX
Zip	:	76112-1451
Country	:	US
Telephone Number	:	817-986-6999
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2015
Last Update Date	:	09/17/2015

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