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General NPI Number Information
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NPI Number | 1063837441
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Entity Type | Organization
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Legal Business Name | HUNTINGTON REPRODUCTIVE CENTER MEDICAL GROUP, A MEDICAL CORPORATION
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Dates
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Enumeration Date | 02/21/2014
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Last Update Date | 08/24/2017
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Provider Practice Location Address
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Address Line | 8112 MILLIKEN AVE STE 101-1
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-7472
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Country | US
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Telephone | 909-941-1120
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Fax | 909-941-1125
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Provider Business Mailing Address
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Address Line | 8112 MILLIKEN AVE STE 101-1
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-7472
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Country | US
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Telephone | 909-941-1120
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Fax | 909-941-1125
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Authorized Official
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Title or Position | PRESIDENT & SHAREHOLDER
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Name | BRADFORD A KOLB
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Credential | M.D.
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Telephone | 626-440-6191
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | CLF344628
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License Number State | CA
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