Provider Demographics
NPI:1083313860
Name:LABORATORIO CLINICO DOMUS CORP
Entity Type:Organization
Organization Name:LABORATORIO CLINICO DOMUS CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IVETTE
Authorized Official - Middle Name:DEL C
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-898-0600
Mailing Address - Street 1:PO BOX 479
Mailing Address - Street 2:
Mailing Address - City:CAMUY
Mailing Address - State:PR
Mailing Address - Zip Code:00627-0479
Mailing Address - Country:US
Mailing Address - Phone:787-898-0600
Mailing Address - Fax:787-609-3546
Practice Address - Street 1:CARR 486 KM 1.9
Practice Address - Street 2:BARRIO ZANJA
Practice Address - City:CAMUY
Practice Address - State:PR
Practice Address - Zip Code:00627-0479
Practice Address - Country:US
Practice Address - Phone:787-820-2170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR8662982772Medicaid