Healthcare Provider Details

I. General information

NPI: 1205457934
Provider Name (Legal Business Name): NUGEN LABS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2020
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EDIFICIO CENTRAL CALLE BALDORIOTY 165 NORTE, BUZON #2
AIBONITO PR
00705
US

IV. Provider business mailing address

EDIFICIO CENTRAL CALLE BALDORIOTY 165 NORTE, BUZON #2
AIBONITO PR
00705
US

V. Phone/Fax

Practice location:
  • Phone: 939-545-0522
  • Fax: 939-545-0700
Mailing address:
  • Phone: 939-545-0522
  • Fax: 939-545-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSE DE TERREFORTE-DIAZ
Title or Position: CEO
Credential: MD, MPH
Phone: 939-545-0522