Healthcare Provider Details

I. General information

NPI: 1114497294
Provider Name (Legal Business Name): JEREMY BRYAN LIPKA CARC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2018
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 MAIN ST STE 309
HOLYOKE MA
01040-5396
US

IV. Provider business mailing address

102 MAIN ST
GREENFIELD MA
01301-3224
US

V. Phone/Fax

Practice location:
  • Phone: 413-316-1446
  • Fax:
Mailing address:
  • Phone: 413-333-9677
  • Fax: 413-773-0477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: