Healthcare Provider Details

I. General information

NPI: 1750766044
Provider Name (Legal Business Name): CITY HOME CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 LAKE AVE N STE 102
WORCESTER MA
01605-2073
US

IV. Provider business mailing address

425 LAKE AVE N STE 102
WORCESTER MA
01605-2073
US

V. Phone/Fax

Practice location:
  • Phone: 617-964-2489
  • Fax: 617-964-2496
Mailing address:
  • Phone: 617-964-2489
  • Fax: 617-964-2490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier110092840B
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name: BORIS LIPSKIY
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 617-964-2489