Provider Demographics
NPI:1164586483
Name:EDGARDO ROMAN
Entity Type:Organization
Organization Name:EDGARDO ROMAN
Other - Org Name:LABORATORIO CLINICO LAGOS DE PLATA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL TECNOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LIZ
Authorized Official - Last Name:VAZQUEZ BOLORIN
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-261-3100
Mailing Address - Street 1:M5 QUINTAS DEL RIO
Mailing Address - Street 2:CAMINO DEL HOSTAL
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961
Mailing Address - Country:US
Mailing Address - Phone:787-261-3100
Mailing Address - Fax:787-261-3113
Practice Address - Street 1:10 DR ALVAREZ CHANCA STREET
Practice Address - Street 2:ESQ AVE SABANA SECA
Practice Address - City:TOA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00949
Practice Address - Country:US
Practice Address - Phone:787-995-4912
Practice Address - Fax:787-261-3113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5715291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory