Provider Demographics
NPI:1457739047
Name:COMMUNITY COACH, INC.
Entity type:Organization
Organization Name:COMMUNITY COACH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:LIBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-586-2222
Mailing Address - Street 1:25 CHRISTY DR
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1813
Mailing Address - Country:US
Mailing Address - Phone:781-760-0650
Mailing Address - Fax:
Practice Address - Street 1:25 CHRISTY DR
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1813
Practice Address - Country:US
Practice Address - Phone:781-760-0650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110079596AMedicaid