Provider Demographics
NPI:1417020603
Name:CITICOACH, INC.
Entity Type:Organization
Organization Name:CITICOACH, INC.
Other - Org Name:TRIPWAY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DMITRIY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEMENOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-777-1277
Mailing Address - Street 1:551 GRAND ST RM 5
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-4282
Mailing Address - Country:US
Mailing Address - Phone:212-777-1277
Mailing Address - Fax:
Practice Address - Street 1:551 GRAND ST RM 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-4282
Practice Address - Country:US
Practice Address - Phone:212-777-1277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYB90348343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02622062Medicaid