Provider Demographics
NPI:1740247253
Name:LABORATORIO CLINICO FAJARDO, INC.
Entity type:Organization
Organization Name:LABORATORIO CLINICO FAJARDO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PRESIDENT OF CORP-LAB. SUPERV
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:IVETTE
Authorized Official - Last Name:AVILES
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-863-5952
Mailing Address - Street 1:40 CARR 194
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-2940
Mailing Address - Country:US
Mailing Address - Phone:787-863-5952
Mailing Address - Fax:787-863-3116
Practice Address - Street 1:40 CARR 194
Practice Address - Street 2:STE. 100 FDO. CINEMA BLDG
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738-2940
Practice Address - Country:US
Practice Address - Phone:787-863-5952
Practice Address - Fax:787-863-3116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1106291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory