MEDICARE: LABORATORIO CLINICO FAGOT, INC.

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	621	PR

General Provider Information

NPI Number	:	1417926189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LABORATORIO CLINICO FAGOT, INC.

Provider Business Mailing Address
First Line	:	2929 AVE EMILIO FAGOT
Second Line	:
City	:	PONCE
State	:	PR
Zip	:	00716-3613
Country	:	US
Telephone Number	:	787-843-7555
Fax Number	:	787-290-0621

Provider Business Practice Location Address
First Line	:	2929 AVE EMILIO FAGOT
Second Line	:
City	:	PONCE
State	:	PR
Zip	:	00716-3613
Country	:	US
Telephone Number	:	787-843-7555
Fax Number	:	787-290-0621

Authorized Official
Title or Position	:	MEDICAL TECHNOLOGIST/OWNER
Name	:	MRS. JOHANNA MARIE PEREZ
Credential	:	BSMT
Telephone Number	:	787-843-7555

Provider Enumeration Date	:	03/15/2006
Last Update Date	:	08/22/2020

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