Provider Demographics
NPI:1811172828
Name:LABORATORIO CLINICO EL CONQUISTADOR I INC
Entity type:Organization
Organization Name:LABORATORIO CLINICO EL CONQUISTADOR I INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:DAMARIS
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-646-4608
Mailing Address - Street 1:CALLE CASTELLON 734 UBANIZACION VISTAMAR
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00983
Mailing Address - Country:UM
Mailing Address - Phone:787-646-4608
Mailing Address - Fax:787-888-4774
Practice Address - Street 1:CENTRO COMERCIAL EL CONQUISTADOR PLAZA COURT
Practice Address - Street 2:CARR. 190, KM 0.7, MARGINAL BALDORIOTY DE CASTRO
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00985
Practice Address - Country:UM
Practice Address - Phone:787-752-2228
Practice Address - Fax:787-752-2715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1145291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
1145OtherHEALTH DEPARTMENT