Provider Demographics
NPI:1376559112
Name:LABORATORIO CLINICO PUERTO NUEVO
Entity Type:Organization
Organization Name:LABORATORIO CLINICO PUERTO NUEVO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:PESQUERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-783-8898
Mailing Address - Street 1:PO BOX 193239
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919-3239
Mailing Address - Country:US
Mailing Address - Phone:787-783-8898
Mailing Address - Fax:787-277-0841
Practice Address - Street 1:1026 AVE FD ROOSEVELT
Practice Address - Street 2:PUERTO NUEVO
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00920-2904
Practice Address - Country:US
Practice Address - Phone:787-783-8898
Practice Address - Fax:787-277-0841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR605291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR=========OtherEIN
PR0030899Medicare ID - Type Unspecified