MEDICARE: IMMIGRANT COMMUNITY DEVELOPMENT CENTER INC

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	363LX0106X	Occupational Health Nurse Practitioner

General Provider Information

NPI Number	:	1366382541
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMMIGRANT COMMUNITY DEVELOPMENT CENTER INC

Provider Business Mailing Address
First Line	:	26 BEAUDRY ST
Second Line	:
City	:	INDIAN ORCHARD
State	:	MA
Zip	:	01151-1704
Country	:	US
Telephone Number	:	413-291-9020
Fax Number	:

Provider Business Practice Location Address
First Line	:	299 CAREW ST STE 134
Second Line	:
City	:	SPRINGFIELD
State	:	MA
Zip	:	01104-2361
Country	:	US
Telephone Number	:	413-291-9020
Fax Number	:

Authorized Official
Title or Position	:	OFFICER
Name	:	RAWAN EBRAHIM
Credential	:	REGISTER NURSE
Telephone Number	:	413-291-9020

Provider Enumeration Date	:	03/30/2026
Last Update Date	:	03/30/2026

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