Provider Demographics
NPI:1043703622
Name:CALIFORNIA CENTRAL COAST IVF LABORATORY
Entity Type:Organization
Organization Name:CALIFORNIA CENTRAL COAST IVF LABORATORY
Other - Org Name:CALIFORNIA CENTRAL COAST IVF LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:CERNY-RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-440-7529
Mailing Address - Street 1:35 CASA ST STE 260
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1890
Mailing Address - Country:US
Mailing Address - Phone:805-440-7529
Mailing Address - Fax:805-466-4229
Practice Address - Street 1:35 CASA ST STE 260
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1890
Practice Address - Country:US
Practice Address - Phone:805-440-7529
Practice Address - Fax:805-466-4229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherNO NUMBERS