Provider Demographics
NPI:1811956345
Name:LABORATORIO ANGEL JELLY GOYCO
Entity type:Organization
Organization Name:LABORATORIO ANGEL JELLY GOYCO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:SEGARRA
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-833-6020
Mailing Address - Street 1:PO BOX 3070
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-3070
Mailing Address - Country:US
Mailing Address - Phone:787-833-6020
Mailing Address - Fax:787-833-6020
Practice Address - Street 1:22 N CALLE DR BASORA
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-0001
Practice Address - Country:US
Practice Address - Phone:787-833-6020
Practice Address - Fax:787-833-6020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR469291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRX15691Medicare UPIN
PR0038178Medicare PIN