Provider Demographics
NPI:1437540671
Name:LABORATORIO CLINICO COUNTRY CLUB
Entity Type:Organization
Organization Name:LABORATORIO CLINICO COUNTRY CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EUGENIO
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-748-4102
Mailing Address - Street 1:1353 AVE LUIS VIGOREAUX
Mailing Address - Street 2:PMB 364
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966-2715
Mailing Address - Country:US
Mailing Address - Phone:787-748-2580
Mailing Address - Fax:787-257-1110
Practice Address - Street 1:758 ROBERTO SANCHEZ VILELLA STREET
Practice Address - Street 2:COUNTRY CLUB
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926
Practice Address - Country:US
Practice Address - Phone:787-748-2580
Practice Address - Fax:787-257-1110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR147291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory