Provider Demographics
NPI:1306814512
Name:LABORATORIO CLINICO LA FUENTE
Entity Type:Organization
Organization Name:LABORATORIO CLINICO LA FUENTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TECNOLOGA
Authorized Official - Prefix:MRS
Authorized Official - First Name:PERSI
Authorized Official - Middle Name:YAMILA
Authorized Official - Last Name:BERNECER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-266-6470
Mailing Address - Street 1:PO BOX 1799
Mailing Address - Street 2:
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00785-1799
Mailing Address - Country:US
Mailing Address - Phone:787-866-6470
Mailing Address - Fax:787-866-6471
Practice Address - Street 1:LA FUENTE TOWN CTR
Practice Address - Street 2:SUITE 108
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00784-6045
Practice Address - Country:US
Practice Address - Phone:787-866-6470
Practice Address - Fax:787-866-6471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1075291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
0031419Medicare ID - Type Unspecified