Provider Demographics
NPI:1487279808
Name:ALPHA FERTILITY ADVANCE LTO
Entity type:Organization
Organization Name:ALPHA FERTILITY ADVANCE LTO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-919-9499
Mailing Address - Street 1:1515 ESSINGTON RD
Mailing Address - Street 2:
Mailing Address - City:JOLLET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-2879
Mailing Address - Country:US
Mailing Address - Phone:815-919-9499
Mailing Address - Fax:815-730-1066
Practice Address - Street 1:1515 ESSINGTON RD
Practice Address - Street 2:
Practice Address - City:JOLLET
Practice Address - State:IL
Practice Address - Zip Code:60435-2879
Practice Address - Country:US
Practice Address - Phone:815-919-9499
Practice Address - Fax:815-730-1066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical