Provider Demographics
NPI:1861812620
Name:HEALTHY LAB GROUP MEDICAL
Entity Type:Organization
Organization Name:HEALTHY LAB GROUP MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:JAVIER
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:I
Authorized Official - Credentials:RT
Authorized Official - Phone:787-972-7980
Mailing Address - Street 1:AC19 CALLE 30
Mailing Address - Street 2:BO. HATO TEJAS REPARTO TERESITA
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00961
Mailing Address - Country:US
Mailing Address - Phone:787-972-7980
Mailing Address - Fax:
Practice Address - Street 1:AC19 CALLE 30
Practice Address - Street 2:BO. HATO TEJAS REPARTO TERESITA
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-8344
Practice Address - Country:US
Practice Address - Phone:787-972-7980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2200332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PROCT232012Medicare PIN