Healthcare Provider Details

I. General information

NPI: 1962065904
Provider Name (Legal Business Name): STORK CLUB FERTILITY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BLUXOME STREET SUITE 203
SAN FRANCISCO CA
94107-5518
US

IV. Provider business mailing address

1 BLUXOME STREET SUITE 203
SAN FRANCISCO CA
94107-5518
US

V. Phone/Fax

Practice location:
  • Phone: 415-801-0467
  • Fax: 415-801-0467
Mailing address:
  • Phone: 415-801-0467
  • Fax: 415-801-0467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MISS JENI MAYORSKAYA
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 415-801-0467