MEDICARE: MEDFORD ADHC

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	261QA0600X	Adult Day Care Clinic/Center		MA

General Provider Information

NPI Number	:	1932566056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDFORD ADHC

Provider Business Mailing Address
First Line	:	101 MYSTIC AVE
Second Line	:
City	:	MEDFORD
State	:	MA
Zip	:	02155-4628
Country	:	US
Telephone Number	:	617-839-8299
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 MYSTIC AVE
Second Line	:
City	:	MEDFORD
State	:	MA
Zip	:	02155-4628
Country	:	US
Telephone Number	:	617-839-8299
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. GENNADIY ITSKIN
Credential	:
Telephone Number	:	617-839-8299

Provider Enumeration Date	:	01/20/2016
Last Update Date	:	06/10/2026

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Directions to “MEDFORD ADHC ” Practice Location

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