=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932566056
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDFORD ADHC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2016
-----------------------------------------------------
Last Update Date | 01/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 MYSTIC AVE
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02155-4628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-839-8299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 MYSTIC AVE
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02155-4628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-839-8299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. GENNADIY ITSKIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 617-839-8299
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------