Basic Information
| Provider Information | |||||||||
| NPI: | 1457626459 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HUNTINGTON REPRODUCTIVE CENTER MEDICAL GROUP, A MEDICAL CORPORATION | ||||||||
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| OtherOrganizationName: | HRC FERTILITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 SUPERIOR AVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926633657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492875600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 SUPERIOR AVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926633657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492875600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2012 | ||||||||
| LastUpdateDate: | 08/24/2017 | ||||||||
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| AuthorizedOfficialLastName: | KOLB | ||||||||
| AuthorizedOfficialFirstName: | BRADFORD | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & SHAREHOLDER | ||||||||
| AuthorizedOfficialTelephone: | 6264406191 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HUNTINGTON REPRODUCTIVE MEDICAL GROUP | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.