Provider Demographics
NPI:1821029257
Name:LABORATORIO CLINICO PUERTO RICO HOLDING, LLC
Entity Type:Organization
Organization Name:LABORATORIO CLINICO PUERTO RICO HOLDING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:GERARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:MARQUEZ-VEGLIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-748-4848
Mailing Address - Street 1:PO BOX 367396
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-7396
Mailing Address - Country:US
Mailing Address - Phone:787-748-4848
Mailing Address - Fax:787-748-4008
Practice Address - Street 1:1747 CARR. 844
Practice Address - Street 2:URB. PURPLE TREE, CUPEY
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-4446
Practice Address - Country:US
Practice Address - Phone:787-748-4848
Practice Address - Fax:787-748-4008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR661291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR30832Medicare ID - Type UnspecifiedLAB PROVIDER