Provider Demographics
NPI:1417915182
Name:LABORATORIO CLINICO CDT
Entity Type:Organization
Organization Name:LABORATORIO CLINICO CDT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNERS
Authorized Official - Prefix:
Authorized Official - First Name:CDT RIVERA LABARCA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA LABARCA
Authorized Official - Suffix:
Authorized Official - Credentials:30656
Authorized Official - Phone:787-846-6890
Mailing Address - Street 1:PO BOX 359
Mailing Address - Street 2:
Mailing Address - City:BARCELONETA
Mailing Address - State:PR
Mailing Address - Zip Code:00617-0359
Mailing Address - Country:US
Mailing Address - Phone:787-846-6890
Mailing Address - Fax:787-846-5458
Practice Address - Street 1:1 CALLE TOMAS DAVILA
Practice Address - Street 2:
Practice Address - City:BARCELONETA
Practice Address - State:PR
Practice Address - Zip Code:00617-2736
Practice Address - Country:US
Practice Address - Phone:787-846-6890
Practice Address - Fax:787-846-5458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR629291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR=========OtherPATRONAL SS
PR30656Medicare ID - Type UnspecifiedMEDICARE