MEDICARE: LABORATORIO CLINICO AQUARIUM 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	957	PR

General Provider Information

NPI Number	:	1922094473
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LABORATORIO CLINICO AQUARIUM INC

Provider Business Mailing Address
First Line	:	PO BOX 970
Second Line	:
City	:	DORADO
State	:	PR
Zip	:	00646
Country	:	US
Telephone Number	:	787-870-2101
Fax Number	:	787-870-4077

Provider Business Practice Location Address
First Line	:	CARR 165 KM 4.7
Second Line	:	PLAZA AQUARIUM SHOPPING MALL
City	:	TOA ALTA
State	:	PR
Zip	:	00953-8836
Country	:	US
Telephone Number	:	787-870-2101
Fax Number	:	787-870-2101

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. JOLLY ORTIZ
Credential	:	MT
Telephone Number	:	787-614-2131

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	03/04/2024

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