Healthcare Provider Details

I. General information

NPI: 1407892060
Provider Name (Legal Business Name): JAIME TAVAREZ PEREZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 11/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE DAGUEY # 58
ANASCO PR
00610-0000
US

IV. Provider business mailing address

PO BOX 956
ISABELA PR
00662-0956
US

V. Phone/Fax

Practice location:
  • Phone: 787-826-3072
  • Fax: 787-826-3072
Mailing address:
  • Phone: 787-872-3480
  • Fax: 787-872-3480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number690
License Number StatePR

VIII. Authorized Official

Name: MR. JAIME TAVAREZ PEREZ
Title or Position: DUENO
Credential:
Phone: 787-872-3480