Healthcare Provider Details

I. General information

NPI: 1750362760
Provider Name (Legal Business Name): MANUEL A GONZALEZ MOLINA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB VILLA MARIA CALLE 1 D2
MANATI PR
00674
US

IV. Provider business mailing address

PO BOX 1249
MANATI PR
00674-1249
US

V. Phone/Fax

Practice location:
  • Phone: 787-854-3202
  • Fax: 787-884-3946
Mailing address:
  • Phone: 787-854-3202
  • Fax: 787-884-3946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number567
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MANUEL A GONZALEZ MOLINA
Title or Position: OWER
Credential:
Phone: 787-854-3202