1316309255 NPI number — LABORATORIO CLINICO LUQUILLO, LLC

Table of content: (NPI 1316309255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316309255 NPI number — LABORATORIO CLINICO LUQUILLO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LABORATORIO CLINICO LUQUILLO, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316309255
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 CARR 194 STE 100
Provider Second Line Business Mailing Address:
FDO CINEMA BLDG
Provider Business Mailing Address City Name:
FAJARDO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00738-2927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-534-4329
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CALLE 13 PARCELA # 52
Provider Second Line Business Practice Location Address:
BARRIO FORTUNA LL
Provider Business Practice Location Address City Name:
LUQUILLO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00773
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-534-4329
Provider Business Practice Location Address Fax Number:
787-534-6586
Provider Enumeration Date:
03/21/2016

Additional Information

Authorized Official

Authorized Official Last Name:
AVILES
Authorized Official First Name:
WANDA
Authorized Official Middle Name:
I
Authorized Official Title or Position:
GENERAL SUPERVISOR
Authorized Official Telephone Number:
787-648-9360

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  1337 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 40 D 2105017 . This is a "CLIA ID NUMBER" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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