MEDICARE: SPERM BANK, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory	CLF 10685	CA

General Provider Information

NPI Number	:	1750615324
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPERM BANK, INC

Provider Business Mailing Address
First Line	:	6699 ALVARADO RD
Second Line	:	STE 2208
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5238
Country	:	US
Telephone Number	:	619-265-0102
Fax Number	:

Provider Business Practice Location Address
First Line	:	6699 ALVARADO RD
Second Line	:	STE 2208
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5238
Country	:	US
Telephone Number	:	619-265-0102
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MR. JOSEPH RICHARD
Credential	:
Telephone Number	:	619-265-0102

Provider Enumeration Date	:	09/29/2009
Last Update Date	:	09/29/2009

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