1316481211 NPI number — LABORATORIO CLINIC OMARIS, INC

Table of content: DR. A NEDRA YULONDA FULLER TERRY DPM (NPI 1902976863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316481211 NPI number — LABORATORIO CLINIC OMARIS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LABORATORIO CLINIC OMARIS, INC
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:
6
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:
1316481211
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
262 CALLE MARGINAL EDIFICIO OMARYS SUITE 4
Provider Second Line Business Mailing Address:
BO PUEBLO
Provider Business Mailing Address City Name:
HATILLO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00659
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-262-7071
Provider Business Mailing Address Fax Number:
787-262-7071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PR 2 KM 86.2 CALLE MARGINAL
Provider Second Line Business Practice Location Address:
BO PUEBLO
Provider Business Practice Location Address City Name:
HATILLO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-262-7071
Provider Business Practice Location Address Fax Number:
787-262-7071
Provider Enumeration Date:
12/12/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ROBLES
Authorized Official First Name:
RIGOBERTO
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
787-262-7071

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  933 , 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: 933 . This is a "PR LICENSE" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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