Provider Demographics
NPI:1639594310
Name:MEDLAB,CORP
Entity Type:Organization
Organization Name:MEDLAB,CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA SERRANO
Authorized Official - Suffix:
Authorized Official - Credentials:MT LIC#6967 PR
Authorized Official - Phone:787-568-8833
Mailing Address - Street 1:PO BOX 725
Mailing Address - Street 2:
Mailing Address - City:SAN SEBASTIAN
Mailing Address - State:PR
Mailing Address - Zip Code:00685-0725
Mailing Address - Country:US
Mailing Address - Phone:787-896-7298
Mailing Address - Fax:
Practice Address - Street 1:PR 109 KM 26.4 INT 497 BO CULEBRINA
Practice Address - Street 2:
Practice Address - City:SAN SEBASTIAN
Practice Address - State:PR
Practice Address - Zip Code:00685
Practice Address - Country:US
Practice Address - Phone:787-896-7298
Practice Address - Fax:787-896-7298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1307291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory