Provider Demographics
NPI:1699855643
Name:FAUSTINO F DEGRO
Entity Type:Organization
Organization Name:FAUSTINO F DEGRO
Other - Org Name:DEGMAR CLINICAL LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-844-6410
Mailing Address - Street 1:PO BOX 331651
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00733-1651
Mailing Address - Country:US
Mailing Address - Phone:787-844-6410
Mailing Address - Fax:787-840-6168
Practice Address - Street 1:8104 CALLE CONCORDIA
Practice Address - Street 2:SUITE #1
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1541
Practice Address - Country:US
Practice Address - Phone:787-844-6410
Practice Address - Fax:787-840-6168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR450291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0038311Medicare PIN