Provider Demographics
NPI:1114920956
Name:MAYAGUEZ ENDOCRINE & CLINICAL LAB
Entity Type:Organization
Organization Name:MAYAGUEZ ENDOCRINE & CLINICAL LAB
Other - Org Name:LABORATORIOS BACO INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:B
Authorized Official - Last Name:BACO BROGINIEZ
Authorized Official - Suffix:
Authorized Official - Credentials:BSMT(ASCP)GS
Authorized Official - Phone:787-429-2007
Mailing Address - Street 1:22 NORTH PERAL ST
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680-4821
Mailing Address - Country:US
Mailing Address - Phone:787-832-7190
Mailing Address - Fax:787-805-2045
Practice Address - Street 1:22 NORTH PERAL ST
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-4821
Practice Address - Country:US
Practice Address - Phone:787-832-7190
Practice Address - Fax:787-805-2045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-24
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR170291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR38028Medicare PIN
PR0038028Medicare PIN