Provider Demographics
NPI:1962065904
Name:STORK CLUB FERTILITY, INC.
Entity type:Organization
Organization Name:STORK CLUB FERTILITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JENI
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYORSKAYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-801-0467
Mailing Address - Street 1:1 BLUXOME STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107-5518
Mailing Address - Country:US
Mailing Address - Phone:415-801-0467
Mailing Address - Fax:415-801-0467
Practice Address - Street 1:1 BLUXOME STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94107-5518
Practice Address - Country:US
Practice Address - Phone:415-801-0467
Practice Address - Fax:415-801-0467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization