Provider Demographics
NPI:1114092566
Name:LABORATORIO CLINICO MIRAMAR INC
Entity Type:Organization
Organization Name:LABORATORIO CLINICO MIRAMAR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AIXA
Authorized Official - Middle Name:
Authorized Official - Last Name:LLORENS BECERRA
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-722-8144
Mailing Address - Street 1:PONCE DE LEON AVE 670
Mailing Address - Street 2:CARIBBEAN TOWERS BLDG STE 5A MIRAMAR
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907
Mailing Address - Country:US
Mailing Address - Phone:787-722-8144
Mailing Address - Fax:787-722-8144
Practice Address - Street 1:PONCE DE LEON AVE 670
Practice Address - Street 2:CARIBBEAN TOWERS BLDG STE 5A MIRAMAR
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907
Practice Address - Country:US
Practice Address - Phone:787-722-8144
Practice Address - Fax:787-722-8144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR672291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
0038131Medicare ID - Type Unspecified