Healthcare Provider Details

I. General information

NPI: 1477640530
Provider Name (Legal Business Name): JUAN LOPEZ VELAQUEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 03/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

961 CALLE MUNOZ RIVERA
PENUELAS PR
00624-1400
US

IV. Provider business mailing address

188 CALLE INVIERNO BRISAS DEL GUAYANES
PENUELAS PR
00624-3012
US

V. Phone/Fax

Practice location:
  • Phone: 787-836-7926
  • Fax:
Mailing address:
  • Phone: 787-836-7926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number1014
License Number StatePR

VIII. Authorized Official

Name: MR. JUAN LOPEZ
Title or Position: GENERAL SUPERVISOR
Credential: MT
Phone: 787-836-7926