Healthcare Provider Details

I. General information

NPI: 1487279808
Provider Name (Legal Business Name): ALPHA FERTILITY ADVANCE LTO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 ESSINGTON RD
JOLLET IL
60435-2879
US

IV. Provider business mailing address

1515 ESSINGTON RD
JOLLET IL
60435-2879
US

V. Phone/Fax

Practice location:
  • Phone: 815-919-9499
  • Fax: 815-730-1066
Mailing address:
  • Phone: 815-919-9499
  • Fax: 815-730-1066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. GRACE LOS
Title or Position: MANAGER
Credential:
Phone: 815-919-9499