Healthcare Provider Details

I. General information

NPI: 1093858946
Provider Name (Legal Business Name): SDFC IVF AND ANDROLOGY LABORATORY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11515 EL CAMINO REAL STE 100
SAN DIEGO CA
92130-3034
US

IV. Provider business mailing address

11515 EL CAMINO REAL STE 100
SAN DIEGO CA
92130-3034
US

V. Phone/Fax

Practice location:
  • Phone: 858-794-6363
  • Fax: 858-794-6360
Mailing address:
  • Phone: 858-794-6363
  • Fax: 858-794-6360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0006X
TaxonomyAmbulatory Fertility Facility
License Number
License Number StateCA

VIII. Authorized Official

Name: LISA VANDOLAH
Title or Position: CEO
Credential: RN,MBA
Phone: 858-720-3177