Provider Demographics
NPI:1215202247
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 1:11500 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 504
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1524
Mailing Address - Country:US
Mailing Address - Phone:310-481-0881
Mailing Address - Fax:
Practice Address - Street 1:11500 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 504
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1524
Practice Address - Country:US
Practice Address - Phone:310-481-0881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HUNTINGTON REPRODUCTIVE MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-08
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLM334936291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory