Provider Demographics
NPI:1174500698
Name:LABORATORO CLINICO EXPRESO TRUJILLO ALTO INC
Entity Type:Organization
Organization Name:LABORATORO CLINICO EXPRESO TRUJILLO ALTO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARDONA
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-748-4102
Mailing Address - Street 1:1353 CARRETERA NO 19
Mailing Address - Street 2:PMB # 364
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966
Mailing Address - Country:US
Mailing Address - Phone:787-748-2580
Mailing Address - Fax:787-292-7966
Practice Address - Street 1:G1B CALLE FRONTERA
Practice Address - Street 2:URB. VILLA ANDALUCIA
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926
Practice Address - Country:US
Practice Address - Phone:787-748-2580
Practice Address - Fax:787-292-7966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR750291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
0038193Medicare PIN