Provider Demographics
NPI:1184747768
Name:ENIDIA VELEZ LOPEZ
Entity type:Organization
Organization Name:ENIDIA VELEZ LOPEZ
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELSIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:VELEZ LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-649-7895
Mailing Address - Street 1:PO BOX 628
Mailing Address - Street 2:
Mailing Address - City:SABANA GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00637-0628
Mailing Address - Country:US
Mailing Address - Phone:787-873-4260
Mailing Address - Fax:
Practice Address - Street 1:39 CALLE LUIS MUNOZ RIVERA
Practice Address - Street 2:
Practice Address - City:SABANA GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00637-1812
Practice Address - Country:US
Practice Address - Phone:787-873-4260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR553291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRCU453AMedicare PIN