Provider Demographics
NPI:1063837441
Name:HUNTINGTON REPRODUCTIVE CENTER MEDICAL GROUP, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:HUNTINGTON REPRODUCTIVE CENTER MEDICAL GROUP, A MEDICAL CORPORATION
Other - Org Name:HRC FERTILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & SHAREHOLDER
Authorized Official - Prefix:
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOLB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-440-6191
Mailing Address - Street 1:8112 MILLIKEN AVE STE 101-1
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-7472
Mailing Address - Country:US
Mailing Address - Phone:909-941-1120
Mailing Address - Fax:909-941-1125
Practice Address - Street 1:8112 MILLIKEN AVE STE 101-1
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7472
Practice Address - Country:US
Practice Address - Phone:909-941-1120
Practice Address - Fax:909-941-1125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-21
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF344628291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1295873677Medicare UPIN