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General NPI Number Information
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NPI Number | 1689731945
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Entity Type | Organization
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Legal Business Name | EASTSIDE FERTILITY LAB INC
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Dates
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Enumeration Date | 01/03/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1370 116TH AVE NE STE 202
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City | BELLEVUE
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State | WA
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Zip | 98004
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Country | US
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Telephone | 425-454-8018
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Fax | 425-635-0742
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Provider Business Mailing Address
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Address Line | 1370 116TH AVE NE STE 100
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City | BELLEVUE
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State | WA
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Zip | 98004
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Country | US
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Telephone | 425-462-6100
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Fax | 425-635-0742
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Authorized Official
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Title or Position | OWNER
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Name | JAMES I KUSTIN
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Credential | MD
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Telephone | 425-688-7740
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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 | MTS-1269
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License Number State | WA
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