Healthcare Provider Details

I. General information

NPI: 1669518445
Provider Name (Legal Business Name): MARISOL COLLAZO ORTIZ INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 12/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 CALLE BARCELO
CIDRA PR
00739-3446
US

IV. Provider business mailing address

12 CALLE BARCELO
CIDRA PR
00739-3446
US

V. Phone/Fax

Practice location:
  • Phone: 787-739-5525
  • Fax: 787-739-2054
Mailing address:
  • Phone: 787-739-5525
  • Fax: 787-739-2054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number807
License Number StatePR

VIII. Authorized Official

Name: MRS. MARISOL COLLAZO
Title or Position: LAB DIRECTOR
Credential: MD MT
Phone: 787-739-5525