Healthcare Provider Details

I. General information

NPI: 1467615724
Provider Name (Legal Business Name): WALMART SC #5802
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PLAZA CANOVANAS PR # 3 KM 17.8
CANOVANAS PR
00729
US

IV. Provider business mailing address

PLAZA CANOVANAS PR #3 KM 17.8
CANOVANAS PR
00729
US

V. Phone/Fax

Practice location:
  • Phone: 787-653-7777
  • Fax: 479-277-4201
Mailing address:
  • Phone: 787-653-7777
  • Fax: 479-277-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MRS. KYLMARIE SERRANO
Title or Position: HEALTH & BEAUTY BUSINESS MANAGER
Credential:
Phone: 787-653-7777