Provider Demographics
NPI:1659365153
Name:LABORATORIO CLINICO VILLA BLANCA,LLC
Entity Type:Organization
Organization Name:LABORATORIO CLINICO VILLA BLANCA,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL TECHNOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUZ
Authorized Official - Middle Name:I
Authorized Official - Last Name:RIOS
Authorized Official - Suffix:
Authorized Official - Credentials:MT ASCP
Authorized Official - Phone:787-746-1686
Mailing Address - Street 1:PO BOX 6782
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-6782
Mailing Address - Country:US
Mailing Address - Phone:787-746-1686
Mailing Address - Fax:787-746-1686
Practice Address - Street 1:58 AQUAMARINA STREET
Practice Address - Street 2:VILLA BLANCA
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00726
Practice Address - Country:US
Practice Address - Phone:787-746-1686
Practice Address - Fax:787-746-1686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-12
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR40D0863294291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
30958Medicare ID - Type Unspecified