Healthcare Provider Details

I. General information

NPI: 1417224940
Provider Name (Legal Business Name): ELITE HEMATOPATHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2011
Last Update Date: 04/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 CALLE MARGINAL VILLAMAR SUITE 3
CAROLINA PR
00979-6300
US

IV. Provider business mailing address

1075 CALLE MARGINAL VILLAMAR SUITE 3
CAROLINA PR
00979-6300
US

V. Phone/Fax

Practice location:
  • Phone: 787-945-7796
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number1278
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. WILFREDO BLASINI
Title or Position: PRESIDENT
Credential:
Phone: 787-945-7796