Provider Demographics
NPI:1790801934
Name:MYRIAM SIMONS MERCADO
Entity Type:Organization
Organization Name:MYRIAM SIMONS MERCADO
Other - Org Name:LABORATORIO CLINICO NAGUABO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MYRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMONS
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAL TECHNOLOGY
Authorized Official - Phone:787-642-6677
Mailing Address - Street 1:PO BOX 602
Mailing Address - Street 2:
Mailing Address - City:RIO BLANCO
Mailing Address - State:PR
Mailing Address - Zip Code:00744-0602
Mailing Address - Country:US
Mailing Address - Phone:787-874-3999
Mailing Address - Fax:
Practice Address - Street 1:26 CALLE BETANCES
Practice Address - Street 2:
Practice Address - City:NAGUABO
Practice Address - State:PR
Practice Address - Zip Code:00718-2513
Practice Address - Country:US
Practice Address - Phone:787-874-3999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR224291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0038207Medicare PIN