Provider Demographics
NPI:1023101516
Name:POTOMAR LABORATORIES INC.
Entity type:Organization
Organization Name:POTOMAR LABORATORIES INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGARITA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:BSMT
Authorized Official - Phone:787-883-1271
Mailing Address - Street 1:PO BOX 1950
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00960-1950
Mailing Address - Country:US
Mailing Address - Phone:787-883-1271
Mailing Address - Fax:787-883-1271
Practice Address - Street 1:SANTA RITA H44 CALLE MARGINAL
Practice Address - Street 2:
Practice Address - City:VEGA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00692
Practice Address - Country:US
Practice Address - Phone:787-883-1271
Practice Address - Fax:787-883-1271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRLICENCE # 689291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRLICENCE # 689OtherDPT. OF HEALTH LICENCE #
PR40D0658222OtherCLIA CMS CERTIFICATE #
PRLICENCE # 689OtherDPT. OF HEALTH LICENCE #