Provider Demographics
NPI:1922094473
Name:LABORATORIO CLINICO AQUARIUM INC
Entity Type:Organization
Organization Name:LABORATORIO CLINICO AQUARIUM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-614-2131
Mailing Address - Street 1:PO BOX 970
Mailing Address - Street 2:
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646
Mailing Address - Country:US
Mailing Address - Phone:787-870-2101
Mailing Address - Fax:787-870-4077
Practice Address - Street 1:CARR 165 KM 4.7
Practice Address - Street 2:PLAZA AQUARIUM SHOPPING MALL
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953-8836
Practice Address - Country:US
Practice Address - Phone:787-870-2101
Practice Address - Fax:787-870-2101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR957291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0031362Medicare PIN