Healthcare Provider Details

I. General information

NPI: 1932566056
Provider Name (Legal Business Name): MEDFORD ADHC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2016
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MYSTIC AVE
MEDFORD MA
02155-4628
US

IV. Provider business mailing address

101 MYSTIC AVE
MEDFORD MA
02155-4628
US

V. Phone/Fax

Practice location:
  • Phone: 617-839-8299
  • Fax:
Mailing address:
  • Phone: 617-839-8299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateMA

VIII. Authorized Official

Name: MR. GENNADIY ITSKIN
Title or Position: OWNER
Credential:
Phone: 617-839-8299