Healthcare Provider Details

I. General information

NPI: 1659646602
Provider Name (Legal Business Name): HUNTINGTON REPRODUCTIVE CENTER MEDICAL GROUP, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2012
Last Update Date: 08/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 SUNNYCREST DR SUITE 2400
FULLERTON CA
92835-3638
US

IV. Provider business mailing address

1950 SUNNYCREST DR SUITE 2400
FULLERTON CA
92835-3638
US

V. Phone/Fax

Practice location:
  • Phone: 714-738-4200
  • Fax:
Mailing address:
  • Phone: 714-738-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberCLM334937
License Number StateCA

VIII. Authorized Official

Name: BRADFORD A KOLB
Title or Position: PRESIDENT & SHAREHOLDER
Credential: M.D.
Phone: 626-440-6191