Provider Demographics
NPI:1588687958
Name:NORTHERN CALIFORNIA FERTILITY MEDICAL CENTER
Entity type:Organization
Organization Name:NORTHERN CALIFORNIA FERTILITY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOENES
Authorized Official - Suffix:
Authorized Official - Credentials:FACMPE
Authorized Official - Phone:916-773-2229
Mailing Address - Street 1:1130 CONROY LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4154
Mailing Address - Country:US
Mailing Address - Phone:916-773-2229
Mailing Address - Fax:916-773-1589
Practice Address - Street 1:1130 CONROY LN
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4154
Practice Address - Country:US
Practice Address - Phone:916-773-2229
Practice Address - Fax:916-773-1589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41427174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty