Provider Demographics
NPI:1437914959
Name:FERTILITY GENETICS LLC
Entity Type:Organization
Organization Name:FERTILITY GENETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF REVENUE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:RAVECH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-305-6640
Mailing Address - Street 1:10290 RIDGEGATE CIR
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-5331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10290 RIDGEGATE CIR
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5331
Practice Address - Country:US
Practice Address - Phone:303-788-8300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Single Specialty
No261QG0250XAmbulatory Health Care FacilitiesClinic/CenterGeneticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
06D2107279OtherCLIA