Provider Demographics
NPI:1578557773
Name:MYRNA SANTIAGO CAMACHO
Entity Type:Organization
Organization Name:MYRNA SANTIAGO CAMACHO
Other - Org Name:LABORATORIO CLINICO HERMANAS DAVILA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MYRNA
Authorized Official - Middle Name:SANTIAGO
Authorized Official - Last Name:CAMACHO
Authorized Official - Suffix:
Authorized Official - Credentials:MT DIRECTOR
Authorized Official - Phone:787-780-8000
Mailing Address - Street 1:PO BOX 51527
Mailing Address - Street 2:
Mailing Address - City:TOA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00950-1527
Mailing Address - Country:US
Mailing Address - Phone:787-780-8000
Mailing Address - Fax:787-795-2064
Practice Address - Street 1:121 AVE BETANCES
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959-5227
Practice Address - Country:US
Practice Address - Phone:787-780-8000
Practice Address - Fax:787-780-8000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-02
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR659291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0038299Medicare PIN