Provider Demographics
NPI:1649522699
Name:LABORATORIO CLINICO Y BACTERIOLOGICO GENESIS
Entity type:Organization
Organization Name:LABORATORIO CLINICO Y BACTERIOLOGICO GENESIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:CARRASQUILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-839-9393
Mailing Address - Street 1:EDIF. LA FUENTE TOWN CENTER SUITE 108
Mailing Address - Street 2:CARR. NUM. PR 54, KM 0.9 MACHETE
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00784
Mailing Address - Country:US
Mailing Address - Phone:787-866-6470
Mailing Address - Fax:787-866-6471
Practice Address - Street 1:CARR NUM 54 KM 0.9 MACHETE
Practice Address - Street 2:SUITE 108 EDIF LA FUENTE TOWN CENTER
Practice Address - City:GUAYAMA
Practice Address - State:PR
Practice Address - Zip Code:00784
Practice Address - Country:US
Practice Address - Phone:787-866-6470
Practice Address - Fax:787-866-6471
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LABORATORIO CLINICO Y BACTERIOLOGICO, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1075291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0031132Medicare PIN