MEDICARE: GILDA WILSON CLINICAL LABORATORY

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	291U00000X	Clinical Medical Laboratory	0012	PR

General Provider Information

NPI Number	:	1386785533
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GILDA WILSON CLINICAL LABORATORY

Provider Business Mailing Address
First Line	:	31 MAYOR ST
Second Line	:
City	:	PONCE
State	:	PR
Zip	:	00730-3726
Country	:	US
Telephone Number	:	787-842-0112
Fax Number	:	787-842-0112

Provider Business Practice Location Address
First Line	:	31 MAYOR ST
Second Line	:
City	:	PONCE
State	:	PR
Zip	:	00730-3726
Country	:	US
Telephone Number	:	787-842-0112
Fax Number	:	787-842-0112

Authorized Official
Title or Position	:	MEDICAL TECHNOLOGIST OWNER
Name	:	MRS. GILDA WILSON
Credential	:	MT
Telephone Number	:	787-842-0112

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	08/06/2007

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