Provider Demographics
NPI:1326219650
Name:LA VIDA MEDICAL GROUP HATILLO CORP
Entity Type:Organization
Organization Name:LA VIDA MEDICAL GROUP HATILLO CORP
Other - Org Name:LABORATORIO CLINICO LOS ANGELES MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:I
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-880-2363
Mailing Address - Street 1:549 CALLE DEL MAR
Mailing Address - Street 2:SUITE 302
Mailing Address - City:HATILLO
Mailing Address - State:PR
Mailing Address - Zip Code:00659-2869
Mailing Address - Country:US
Mailing Address - Phone:787-880-2363
Mailing Address - Fax:787-881-4312
Practice Address - Street 1:549 CALLE DEL MAR
Practice Address - Street 2:SUITE 302
Practice Address - City:HATILLO
Practice Address - State:PR
Practice Address - Zip Code:00659-2869
Practice Address - Country:US
Practice Address - Phone:787-880-2363
Practice Address - Fax:787-881-4312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory