Provider Demographics
NPI:1972063618
Name:LABORATORIO CLINICO EBENEZER LLC
Entity Type:Organization
Organization Name:LABORATORIO CLINICO EBENEZER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ENILDA
Authorized Official - Middle Name:
Authorized Official - Last Name:VELAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PB MT, MLS (ASCP)
Authorized Official - Phone:787-233-1313
Mailing Address - Street 1:2C25 AVE C
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00987-7481
Mailing Address - Country:US
Mailing Address - Phone:787-220-1558
Mailing Address - Fax:
Practice Address - Street 1:PR 8860 KM 1.2
Practice Address - Street 2:PLAZA MATIENZO BO CUEVAS
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976
Practice Address - Country:US
Practice Address - Phone:787-233-1313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1255788386Medicaid