Provider Demographics
NPI:1477675288
Name:LABORATORIO CLINICO BACO STAT - LABI
Entity Type:Organization
Organization Name:LABORATORIO CLINICO BACO STAT - LABI
Other - Org Name:LABORATORIOS BACO INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:B
Authorized Official - Last Name:BACO
Authorized Official - Suffix:
Authorized Official - Credentials:MT (DSCP)
Authorized Official - Phone:787-429-2007
Mailing Address - Street 1:22 CALLE PERAL NORTE
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00680-4821
Mailing Address - Country:US
Mailing Address - Phone:787-832-7190
Mailing Address - Fax:787-805-2045
Practice Address - Street 1:975 AVE. HOSTOS, CARR #2, SUITE 590
Practice Address - Street 2:CENTRO COMERCIAL MAYAGUEZ MALL
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680
Practice Address - Country:US
Practice Address - Phone:787-833-0033
Practice Address - Fax:787-805-2760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR727291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0038316Medicare PIN
PR0031366Medicare PIN