MEDICARE: LABORATORIO CLINICO PUERTO RICO HOLDING, LLC

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	661	PR

General Provider Information

NPI Number	:	1821029257
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LABORATORIO CLINICO PUERTO RICO HOLDING, LLC

Provider Business Mailing Address
First Line	:	PO BOX 367396
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00936-7396
Country	:	US
Telephone Number	:	787-748-4848
Fax Number	:	787-748-4008

Provider Business Practice Location Address
First Line	:	1747 CARR. 844
Second Line	:	URB. PURPLE TREE, CUPEY
City	:	SAN JUAN
State	:	PR
Zip	:	00926-4446
Country	:	US
Telephone Number	:	787-748-4848
Fax Number	:	787-748-4008

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT
Name	:	MRS. GERARDO MARQUEZ-VEGLIO
Credential	:
Telephone Number	:	787-748-4848

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	08/01/2013

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