Provider Demographics
NPI:1144384256
Name:ROSA M. HEREDIA CASTILLO
Entity Type:Organization
Organization Name:ROSA M. HEREDIA CASTILLO
Other - Org Name:LABORATORIO CLINICO LECORD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HEREDIA
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-722-0341
Mailing Address - Street 1:PO BOX 367331
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-7331
Mailing Address - Country:US
Mailing Address - Phone:787-722-0341
Mailing Address - Fax:787-722-0341
Practice Address - Street 1:260 AVE DE LA CONSTITUCION
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00901-2298
Practice Address - Country:US
Practice Address - Phone:787-722-0341
Practice Address - Fax:787-722-0341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR768291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
0030703Medicare PIN