Provider Demographics
NPI:1093797946
Name:LABORATORIO CLINICO Y BACTERIOLOGICO DE DIEGO
Entity Type:Organization
Organization Name:LABORATORIO CLINICO Y BACTERIOLOGICO DE DIEGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELBA
Authorized Official - Middle Name:ENID
Authorized Official - Last Name:MANZANO
Authorized Official - Suffix:
Authorized Official - Credentials:MT (ASCP)
Authorized Official - Phone:787-833-0470
Mailing Address - Street 1:PO BOX 7301
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-7301
Mailing Address - Country:US
Mailing Address - Phone:787-833-0470
Mailing Address - Fax:787-833-0470
Practice Address - Street 1:CALLE DE DIEGO # 51 ESTE
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680
Practice Address - Country:US
Practice Address - Phone:787-833-0470
Practice Address - Fax:787-833-0470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR304291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory