Provider Demographics
NPI:1609184225
Name:WAXALI INC
Entity Type:Organization
Organization Name:WAXALI INC
Other - Org Name:LABORATORIO CLINICO ISLA CENTRO BARRANQUITAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLLAZO ROSADO
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-869-1111
Mailing Address - Street 1:HC 72 BOX 3954
Mailing Address - Street 2:
Mailing Address - City:NARANJITO
Mailing Address - State:PR
Mailing Address - Zip Code:00719-8771
Mailing Address - Country:US
Mailing Address - Phone:787-869-1111
Mailing Address - Fax:787-869-2318
Practice Address - Street 1:17 CALLE MUNOZ RIVERA
Practice Address - Street 2:SUITE 1
Practice Address - City:BARRANQUITAS
Practice Address - State:PR
Practice Address - Zip Code:00794-1755
Practice Address - Country:US
Practice Address - Phone:787-857-2246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAXALI INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-16
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR232291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR10-113OtherCNC
PR232OtherSTATE LICENCE
40D0667627OtherCLIA