MEDICARE: MRS. ELIZABETH ALICEA MEDICAL TECHNOLOGIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247ZC0005X	Clinical Laboratory Director (Non-physician)	2395	PR

General Provider Information

NPI Number	:	1134318405
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELIZABETH ALICEA MEDICAL TECHNOLOGIST

Provider Business Mailing Address
First Line	:	PO BOX 6157
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00914-6157
Country	:	US
Telephone Number	:	787-448-3109
Fax Number	:

Provider Business Practice Location Address
First Line	:	JR1 CALLE LIZZIE GRAHAM
Second Line	:
City	:	TOA BAJA
State	:	PR
Zip	:	00949-3637
Country	:	US
Telephone Number	:	787-448-3109
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2007
Last Update Date	:	10/23/2007

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