Provider Demographics
NPI:1316021504
Name:LABORATORIO CLINICO FAIR VIEW CSP
Entity Type:Organization
Organization Name:LABORATORIO CLINICO FAIR VIEW CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTEGA VERGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-292-8789
Mailing Address - Street 1:EL SENORIAL MAIL STATION
Mailing Address - Street 2:MSC 779
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6023
Mailing Address - Country:US
Mailing Address - Phone:787-292-8789
Mailing Address - Fax:787-292-8757
Practice Address - Street 1:CARRETERA 845 KM 3.3
Practice Address - Street 2:CENTRO COMERCIAL FAIRVIEW SUITE 7
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976
Practice Address - Country:US
Practice Address - Phone:787-292-8789
Practice Address - Fax:787-292-8757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1051291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0031245Medicare PIN