Provider Demographics
NPI:1114077955
Name:LABORATORIO CLINICO DEL SURESTE
Entity Type:Organization
Organization Name:LABORATORIO CLINICO DEL SURESTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:YANIRE
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTRO-TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-893-2595
Mailing Address - Street 1:PO BOX 1340
Mailing Address - Street 2:
Mailing Address - City:YABUCOA
Mailing Address - State:PR
Mailing Address - Zip Code:00767-1340
Mailing Address - Country:US
Mailing Address - Phone:787-893-2595
Mailing Address - Fax:787-893-2716
Practice Address - Street 1:34 CALLE LUIS MUNOZ RIVERA
Practice Address - Street 2:
Practice Address - City:YABUCOA
Practice Address - State:PR
Practice Address - Zip Code:00767-3110
Practice Address - Country:US
Practice Address - Phone:787-893-2595
Practice Address - Fax:787-893-2716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR216291U00000X
PR569291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0031030Medicare ID - Type UnspecifiedLAB COLON #2 40D0701113