Provider Demographics
NPI:1750362760
Name:MANUEL A GONZALEZ MOLINA
Entity type:Organization
Organization Name:MANUEL A GONZALEZ MOLINA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWER
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GONZALEZ MOLINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-854-3202
Mailing Address - Street 1:PO BOX 1249
Mailing Address - Street 2:
Mailing Address - City:MANATI
Mailing Address - State:PR
Mailing Address - Zip Code:00674-1249
Mailing Address - Country:US
Mailing Address - Phone:787-854-3202
Mailing Address - Fax:787-884-3946
Practice Address - Street 1:URB VILLA MARIA CALLE 1 D2
Practice Address - Street 2:
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-854-3202
Practice Address - Fax:787-884-3946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR567291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
0030352Medicare PIN