Provider Demographics
NPI:1275629388
Name:LABORATORIO TERESITA
Entity Type:Organization
Organization Name:LABORATORIO TERESITA
Other - Org Name:LABORATORIO CLINICO EBENEZER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DUENA
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:ZAMARA
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-675-0112
Mailing Address - Street 1:40 CALLE MUNOZ RIVERA
Mailing Address - Street 2:
Mailing Address - City:VEGA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00692-6530
Mailing Address - Country:US
Mailing Address - Phone:787-883-1009
Mailing Address - Fax:787-883-1009
Practice Address - Street 1:40 CALLE MUNOZ RIVERA
Practice Address - Street 2:
Practice Address - City:VEGA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00692-6530
Practice Address - Country:US
Practice Address - Phone:787-883-1009
Practice Address - Fax:787-883-1009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR720291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
20225BOtherPMC
66049465902OtherHUMANA
660494659087OtherIMC
800232OtherSSS
31282OtherSSS
7620023AOtherHUMANA
7620023AOtherHUMANA
=========087OtherIMC