Provider Demographics
NPI:1003078403
Name:REPROSOURCE FERTILITY DIAGNOSTICS, INC
Entity Type:Organization
Organization Name:REPROSOURCE FERTILITY DIAGNOSTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEADER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:800-667-8893
Mailing Address - Street 1:300 TRADE CENTER
Mailing Address - Street 2:SUITE 6540
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801
Mailing Address - Country:US
Mailing Address - Phone:800-667-8893
Mailing Address - Fax:781-935-3068
Practice Address - Street 1:300 TRADE CENTER
Practice Address - Street 2:SUITE 6540
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801
Practice Address - Country:US
Practice Address - Phone:800-667-8893
Practice Address - Fax:781-935-3068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2554291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory