Provider Demographics
NPI:1407172042
Name:KETTERING REPRODUCTIVE LABORATORY INC
Entity Type:Organization
Organization Name:KETTERING REPRODUCTIVE LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAXIM
Authorized Official - Middle Name:E
Authorized Official - Last Name:RYGOVSKIY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-687-7975
Mailing Address - Street 1:8210 MACEDONIA COMMONS BLVD
Mailing Address - Street 2:STE 68-105
Mailing Address - City:MACEDONIA
Mailing Address - State:OH
Mailing Address - Zip Code:44056-1860
Mailing Address - Country:US
Mailing Address - Phone:330-687-7975
Mailing Address - Fax:
Practice Address - Street 1:3533 SOUTHERN BLVD
Practice Address - Street 2:STE 4100
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1264
Practice Address - Country:US
Practice Address - Phone:330-687-7975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36D0957636291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory