MEDICARE: ALPHA FERTILITY ADVANCE LTO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0050X	Non-Surgical Family Planning Clinic/Center

General Provider Information

NPI Number	:	1487279808
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALPHA FERTILITY ADVANCE LTO

Provider Business Mailing Address
First Line	:	1515 ESSINGTON RD
Second Line	:
City	:	JOLLET
State	:	IL
Zip	:	60435-2879
Country	:	US
Telephone Number	:	815-919-9499
Fax Number	:	815-730-1066

Provider Business Practice Location Address
First Line	:	1515 ESSINGTON RD
Second Line	:
City	:	JOLLET
State	:	IL
Zip	:	60435-2879
Country	:	US
Telephone Number	:	815-919-9499
Fax Number	:	815-730-1066

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. GRACE LOS
Credential	:
Telephone Number	:	815-919-9499

Provider Enumeration Date	:	06/11/2020
Last Update Date	:	06/11/2020

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