Provider Demographics
NPI:1619195492
Name:LABORATORIO CLINICO UNIVERSITARIO
Entity Type:Organization
Organization Name:LABORATORIO CLINICO UNIVERSITARIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:ROSINA
Authorized Official - Last Name:DE JESUS
Authorized Official - Suffix:
Authorized Official - Credentials:BS MT
Authorized Official - Phone:787-780-0611
Mailing Address - Street 1:EXT. HNAS DAVILA
Mailing Address - Street 2:CALLE 2, J-12
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00959
Mailing Address - Country:US
Mailing Address - Phone:787-780-0611
Mailing Address - Fax:787-780-0611
Practice Address - Street 1:EXT. HNAS DAVILA
Practice Address - Street 2:CALLE 2, J-12
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-780-0611
Practice Address - Fax:787-780-0611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR420291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR420OtherPUERTO RICO LICENSE
PR30326Medicare ID - Type Unspecified