Provider Demographics
NPI:1770559742
Name:LABORATORIO CLINICO COLISEO INC
Entity type:Organization
Organization Name:LABORATORIO CLINICO COLISEO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MALAVET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-842-4007
Mailing Address - Street 1:2525 AVE E RUBERTE
Mailing Address - Street 2:COLISEO SHOPPING CENTER SUITE 211
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00728-1712
Mailing Address - Country:US
Mailing Address - Phone:787-842-4007
Mailing Address - Fax:787-841-7223
Practice Address - Street 1:2525 AVE E RUBERTE
Practice Address - Street 2:COLISEO SHOPPING CENTER SUITE 211
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00728-1712
Practice Address - Country:US
Practice Address - Phone:787-842-4007
Practice Address - Fax:787-841-7223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
435291U00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR2004OtherFIRST MEDICAL
PR7320025OtherHUMANA HEALTH
PR050601OtherCRUZ AZUL
PR800116OtherM.M.M. HEALTHCARE
PR30288OtherSSS
PR7320025OtherHUMANA INSURANCE
PR30288OtherSSS
PR7320025OtherHUMANA HEALTH
PR800116OtherM.M.M. HEALTHCARE
PR=========OtherCIGNA PREFERRED