Provider Demographics
NPI:1457763997
Name:LABORATORIO CLINICO DIVINO NINO, INC.
Entity Type:Organization
Organization Name:LABORATORIO CLINICO DIVINO NINO, INC.
Other - Org Name:LABORATORIO CLINICO DIVINO NINO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:BRENDALIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:AVILES
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-635-8154
Mailing Address - Street 1:PO BOX 987
Mailing Address - Street 2:
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-0987
Mailing Address - Country:US
Mailing Address - Phone:787-551-7175
Mailing Address - Fax:
Practice Address - Street 1:BO. PLATA CARR. 420 KM 4.4
Practice Address - Street 2:
Practice Address - City:MOCA
Practice Address - State:PR
Practice Address - Zip Code:00676
Practice Address - Country:US
Practice Address - Phone:787-551-7175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1312291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory