Provider Demographics
NPI:1821127150
Name:LABORATORIO CLINICO MAYAGUEZ
Entity Type:Organization
Organization Name:LABORATORIO CLINICO MAYAGUEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ENEIDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-274-0551
Mailing Address - Street 1:142 CALLE MAYAGUEZ
Mailing Address - Street 2:PEREZ MORRIS
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00917-5117
Mailing Address - Country:US
Mailing Address - Phone:787-274-0551
Mailing Address - Fax:163-073-3367
Practice Address - Street 1:142 CALLE MAYAGUEZ
Practice Address - Street 2:PEREZ MORRIS
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917-5117
Practice Address - Country:US
Practice Address - Phone:787-274-0551
Practice Address - Fax:787-274-0551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-04
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR930291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory