Provider Demographics
NPI:1275719874
Name:LAB CLINICO Y BACTERIOLOGICO EBENEZER
Entity Type:Organization
Organization Name:LAB CLINICO Y BACTERIOLOGICO EBENEZER
Other - Org Name:MARIA ELENA NIEVES MUNIZ
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:ELENA
Authorized Official - Last Name:NIEVES
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-882-1785
Mailing Address - Street 1:PO BOX 3538
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00605-3538
Mailing Address - Country:US
Mailing Address - Phone:787-882-1785
Mailing Address - Fax:787-882-1785
Practice Address - Street 1:ROAD 2 KM 118 HM4
Practice Address - Street 2:BO. CEIBA BAJA
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603-0000
Practice Address - Country:US
Practice Address - Phone:787-882-1785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2024-05-07
Deactivation Date:2008-07-22
Deactivation Code:
Reactivation Date:2015-06-24
Provider Licenses
StateLicense IDTaxonomies
PR1003291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0030132Medicare PIN