Provider Demographics
NPI:1790909265
Name:LABORATORIO CLINICO Y DE REFERENCIA DE FAJARDO, INC.
Entity Type:Organization
Organization Name:LABORATORIO CLINICO Y DE REFERENCIA DE FAJARDO, INC.
Other - Org Name:LABORATORIO CLINICO SAN FERNANDO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-885-0813
Mailing Address - Street 1:210 AVE LAURO PINERO
Mailing Address - Street 2:
Mailing Address - City:CEIBA
Mailing Address - State:PR
Mailing Address - Zip Code:00735-2737
Mailing Address - Country:US
Mailing Address - Phone:787-885-0813
Mailing Address - Fax:787-885-0831
Practice Address - Street 1:303 GENERAL VALERO AVE
Practice Address - Street 2:
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738-7006
Practice Address - Country:US
Practice Address - Phone:787-885-0813
Practice Address - Fax:787-885-0831
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LABORATORIO CLINICO Y DE REFERENCIA DE FAJARDO, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-13
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR850291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR38123Medicare ID - Type Unspecified